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HUGHES'  PRACTICE  OF  MEDICINE 


SCOTT 


ELEVENTH  EDITION 


HUGHES' 

PRACTICE   OF  MEDICINE 

INCLUDING  A  SECTION  ON  MENTAL  DISEASES 
AND  ONE  ON  DISEASES  OF  THE  SKIN 

ELEVENTH  EDITION  REVISED  AND  ENLARGED 


BY 

R.  J.  E.  SCOTT,  M.  A.,  B.  C.  L.,  M.  D. 

NEW  YORK 

FELLOW  OF  THE    NEW  YORK    ACADEMY   OF  MEDICINE;  FELLOW  OF  THE  AMERICAN  MEDI- 
CAL association;  formerly  attending  physician  to  the  demilt  dispen- 
sary; FORMERLY  ATTENDING  PHYSICIAN  TO  THE  BELLEVUE  DISPENSARY; 
AUTHOR  OF   "THE  STATE  BOARD    EXAMINATION    SERIES;"    EDITOR 
OF     "WITTHAUS'     ESSENTIALS    OF    CHEMISTRY    AND    TOXI- 
COLOGY*', "THE  PRACTITIONER'S  MEDICAL  DICTION- 
ARY",    GOULD    AND    PYLE's    "CYCLOPEDIA 
OF  MEDICINE  AND  SURGERY;" 
ETC.,   ETC. 


W^ITH  63  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO. 

1012  V^ALNUT  STREET 


Copyright,  19 17,  by  P.  Blakiston's  Son  &  Co. 


THE    AIAPX,E    PKESS    TrORKTA 


PREFACE  TO  THE  ELEVENTH  EDITION 


The  tenth  edition  of  this  work  underwent  a  thorough  revision ;  the 
call  for  another  edition  now  renders  it  possible  to  incorporate  much 
new  material  as  well  as  to  make  such  changes  as  are  necessitated  by 
the  advances  of  Medical  Science.  New  articles  will  be  found  on 
Syphilis,  Heart-Block,  Kala-Azar,  Rocky  Mountain  Spotted  Fever, 
Milk  Sickness,  Acute  Febrile  Jaundice,  Erythremia,  and  Vincent's 
Angina.  Important  additions  have  been  made  to  several  chapters, 
among  which  may  be  mentioned  the  paragraphs  on  Blood-Pressure, 
the  Color  Index  of  the  Blood,  the  Dietetic  Treatment  of  Diabetes 
Mellitus,  Lambert's  Treatment  of  Narcotic  Addiction,  Coleman's 
High  Calorie  Diet  in  Typhoid  and  Other  Fevers,  Typhoid  State,  the 
Etiology  of  Typhus  Fever,  Russo's  Test,  the  Vitamine  Theory  of 
Rickets,  Schick's  Reaction,  MacEwen's  Sign,  Brudzinski's  Sign,  the 
Use  of  Vaccines,  and  the  Period  of  Quarantine  for  Most  of  the  Com- 
municable Diseases.  Some  new  prescriptions  have  been  added,  and 
a  few  of  the  old  ones  have  been  omitted. 

It  has,  again,  been  assumed  that  Diagnosis  and  Treatment  are  the 
main  business  of  the  practitioner,  and  that  those  who  use  this  book 
are  anxious  to  find  out  what  is  the  matter  with  their  patients,  and 
then  to  alleviate  or  cure,  as  the  case  may  be.  It  should  also  be  borne 
in  mind  that,  for  the  practitioner  of  today,  the  tried  methods  of 
yesterday  are  safer  (and  therefore  better)  than  the  theories  of  to- 
morrow: hence,  anything  that  has  not  stood  the  test  of  time  and 
criticism  has  found  no  place  herein. 

R.  J.  E.  Scott. 

New  York. 


PREFACE  TO  THE  TENTH  EDITION 


The  time  that  has  elapsed  since  the  appearance  of  the  last  edition 
has  necessitated  very  many  changes  and  additions.  The  Table  of 
Contents  will  show  that  the  general  arrangement  has  been  consider- 
ably modified.  For  example,  Pneumonia  and  Tuberculosis  no  longer 
appear  as  Diseases  of  the  Lungs,  but  take  their  rightful  place  among 
the  Infectious  Diseases;  and  Herpes  Zoster  will  be  found  among  the 
Diseases  of  the  Nerves,  rather  than  among  the  Skin  lesions.  Several 
new  sections  have  been  added,  such  as  Pellagra,  Glandular  Fever, 
Foul  Breath,  Cammidge's  Reaction,  Paralysis  of  the  Laryngeal  Mus- 
cles. The  book  as  a  whole  has  been  thoroughly  revised,  much  of  it 
has  been  rewritten,  sections  that  were  obsolete  or  unnecessary  have 
been  omitted,  and  almost  every  page  shows  changes.  The  new  edi- 
tion contains  one  hundred  pages  of  reading  matter  more  than  the 
previous  one,  besides  a  much  fuller  index.  Some  of  the  older  pre- 
scriptions have  been  discarded,  and  many  new  ones  have  been  intro- 
duced. The  sections  on  treatment  will  be  found  much  more  com- 
plete, and  the  prescriptions  more  numerous,  than  in  any  other  similar 
work.  It  has  been  assumed  that  Diagnosis  and  Treatment  are  the 
main  business  of  the  practitioner,  and  that  those  who  use  this  book 
are  anxious  to  find  out  what  is  the  matter  with  their  patients,  and 
then  to  alleviate  or  cure,  as  the  case  may  be.  To  this  end  numerous 
tables  of  differential  diagnosis  have  been  added,  and  other  useful 
summaries  have  been  incorporated  into  the  text.  The  number  of 
charts  and  illustrations  has  been  increased  from  27  to  63;  and  every 
effort  has  been  made  to  render  the  volume  as  useful  as  possible  to 
both  students  and  practitioners.  A  few  paragraphs  have  already 
appeared  in  the  Medical  Record,  under  the  heading  of  State  Board 
Questions  and  Answers;  and  acknowledgment  is  hereby  made  to  the 
Editor  and  Publishers  of  that  paper  for  permission  to  reproduce  the 
same. 

R.   J.  E.  Scott. 

New  York. 


Vll 


CONTENTS 


Page 

Introduction i 

INFECTIOUS  DISEASES 

Fevers 5 

Table  of  Exanthemata 8 

Simple  Continued  Fever 9 

Influenza .' lo 

Typhoid  Fever 14 

Paratyphoid  Fever 28 

Typhus  Fever »    .  28 

Cerebrospinal  Fever 30 

Acute  Poliomyelitis 34 

Relapsing  Fever 38 

Malta  Fever 39 

Malaria 40 

Intermittent  Fever 44 

Remittent  Fever 47 

Pernicious  Malarial  Fever 48 

Malarial  Cachexia 50 

Blackwater  Fever 50 

Yellow  Fever 51 

Dengue 55 

Scarlet  Fever 56 

Measles 62 

Rubella 65 

Small-pox 66 

Vaccination • 70 

Varicella 73 

Erysipelas 73 

Mumps 75 

Diphtheria 77 

Vincent's  Angina 86 

Glanders  and  Farcy 87 

Foot  and  Mouth  Disease 88 

Syphilis 89 

Acquired  Syphilis 9^ 

Congenital  Syphilis loi 

Cholera 105 

ix 


X  CONTENTS 

Page 

Dysentery .112 

Trypanosomiasis 118 

Kala-Azar 119 

Bubonic  Plague 119 

Tetanus 121 

Hydrophobia  .    , 123 

Anthrax 125 

Whooping  Cough 126 

Rheumatic  Fever 129 

Lobar  Pneumonia 134 

Tuberculosis 146 

Pulmonary  Tuberculosis 146 

Acute  MiHary  Tuberculosis 146 

Pneumonic  Phthisis 149 

Tuberculous  Phthisis'. 152 

Fibroid  Phthisis      156 

Treatment  of  Pulmonary  Tuberculosis 157 

Leprosy 162 

Glandular  Fever 164 

Rocky  Mountain  Spotted  Fever 165 

Milk  Sickness 165 

Acute  Febrile  Jaundice 166 

CONSTITUTIONAL  DISEASES 

Chronic  Articular  Rheumatism 166 

Muscular  Rheumatism 167 

Arthritis  Deformans 169 

Gout 172 

Rickets 175 

Diabetes  Mellitus 176 

Diabetes  Insipidus 183 

THE  INTOXICATIONS  AND  SUNSTROKE 

Alcoholism 185 

Chronic  Opium  Poisoning 192 

Pellagra 195 

Heat  Stroke 195 

Caisson  Disease 198 

DISEASES  OF  THE  DIGESTIVE  SYSTEM 

DISEASES    OF    THE    MOUTH 

Introduction 198 

Catarrhal  Stomatitis 199 


CONTENTS  XI 

Page 

Aphthous  Stomatitis 200 

Ulcerative  Stomatitis 201 

Thrush 201 

Gangrenous  Stomatitis 202 

Mercurial  Stomatitis 203 

Ludwig's  Angina 204 

DISEASES    OF    THE    TONGUE 

Coating  of  the  Tongue 204 

Glossitis 205 

Syphilis  of  the  Tongue 205 

Ulceration  of  the  Tongue 205 

Leukoplakia  Buccalis 206 

Foul  Breath 206 

DISEASES    OF    THE    PHARYNX    AND    TONSILS 

Acute  Catarrhal  Pharyngitis 207 

Chronic  Pharyngitis 208 

Ulceration  of  the  Pharynx »  209 

Acute  Tonsillitis. 209 

Hypertrophy  of  the  Tonsils 211 

DISEASES   OF   THE   ESOPHAGUS 

Esophagitis 212 

Esophageal  Obstruction , 212 

Cancer  of  the  Esophagus 213 

DISEASES    OF    THE    STOMACH 

Diagnostic  Technic 214 

External  Examination 214 

Internal  Examination.     (Examination  of  Stomach  Contents.) .  215 

Acute  Gastritis 219 

Irritant  and  Corrosive  Poisons 222 

Chronic  Gastritis 223 

Peptic  Ulcer;  Gastric,  and  Duodenal 227 

Cancer  of  the  Stomach 231 

Gastric  Dilatation      234 

Gastroptosis 235 

HematemewSis , 236 

Gastralgia 238 

Dyspepsia 240 


Xll  CONTENTS 

DISEASES    OF   THE   INTESTINES 

Page 

Intestinal  Indigestion 243 

Intestinal  Colic 246 

Constipation - 247 

Diarrhea 249 

Catarrhal  Enteritis 252 

Croupous  Enteritis 255 

Cholera  Morbus 256 

Enterocolitis .    .  258 

Cholera  Infantum 262 

Appendicitis 264 

Proctitis 268 

Intestinal  Obstruction 269 

INTESTINAL    PARASITES 

Tapeworms — Cestodes 273 

Roundworms — Nematodes • 276 

Dracontiasis  (Guinea  Worm  Disease) 282 

DISEASES    OF    THE    LIVER 

Preliminary  Considerations ' 282 

Congestion  of  the  Liver 284 

Abscess  of  the  Liver 286 

Acute  Yellow  Atrophy 287 

Cirrhosis  of  the  Liver 289 

Amyloid  Liver 292 

Hydatid  Cyst  of  the  Liver 293 

Syphilis  of  the  Liver 294 

Carcinoma  of  the  Liver 294 

Sarcoma  of  the  Liver 296 

DISEASES    OF    THE    BILE    PASSAGES    AND    GALL    BLADDER 

Jaundice 296 

Cholelithiasis 298 

Acute  Infectious  Cholecystitis 301 

DISEASES    OF    THE    PANCREAS 

Acute  Pancreatitis 302 

Chronic  Pancreatitis 303 

Cancer  of  the  Pancreas 304 

Cysts  of  the  Pancreas 304 

Pancreatic  Calculi 305 


CONTENTS  Xlll 


DISEASES    OF   THE    PERITONEUM 

Page 

Peritonitis 3^5 

Ascites 309 

DISEASES  OF  THE  URINARY  ORGANS 
The  Urine 311 


DISEASES    OF    THE    KIDNEYS    AND   BLADDER 

Congestion  of  the  Kidneys 326 

Acute  Parenchymatous  Nephritis 327 

Chronic  Parenchymatous  Nephritis 330 

Chronic  Intestinal  Nephritis 333 

Amyloid  Kidney 33^ 

Pyelitis 339 

Nephrolithiasis 34^ 

Hydronephrosis 344 

Tuberculosis  of  the  Kidney 345 

Perinephritic  Abscess,  or  Paranephritis 345 

Acute  Uremia 345 

Movable  Kidney 349 

Cystitis 351 

DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS 

Examination  of  the  Blood ' 354 

Abnormal  States  of  the  Blood 359 

Anemia 361 

Chlorosis 362 

Progressive  Pernicious  Anemia 365 

Leukocythemia 3^7 

Pseudoleukocythemia ,  370 

Erythremia 37 1 

Hemophilia 37^ 

Scorbutus 372 

Purpiira 374 

Status  Lymphaticus  . 375 

Splenic  Anemia 37^ 

Addison's  Disease 37^ 

Exophthalmic  Goitre 377 

Myxedema 379 

Tetany 380 

Acromegaly 382 


XIV  CONTENTS 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

Page 

Physical  Diagnosis 382 

Symptomatology 389 

DISEASES    OF    THE    PERICARDIUM 

Acute  Pericarditis 393 

Chronic  Pericarditis 397 

Hydropericardium 398 

DISEASES    OF    THE    ENDOCARDIUM 

Acute  Endocarditis 399 

Malignant  Endocarditis 401 

Chronic  Endocarditis 402 

Mitral  Regurgitation 403 

Aortic  Regurgitation 404 

Tricuspid  Regurgitation 409 

Pulmonary  Regurgitation 410 

Mitral  Obstruction 410 

Aortic  Obstruction. 411 

Tricuspid  Obstruction 412 

Pulmonary  Obstruction 413 

Relative  Frequency  of  Valvular  Defects 413 

Combined  Valvular  Lesions '".' 413 

Diagnosis,  Prognosis,  and  Treatment  of  Valvular  Diseases    .    .    .    .414 

DISEASES    OF   THE   MYOCARDIUM 

Hypertrophy  of  the  Heart 417 

Dilatation  of  the  Heart 419 

Acute  Myocarditis 422 

Chronic  Myocarditis 423 

Fatty  Heart 426 

FUNCTIONAL    AFFECTIONS    OF    THE    HEART 

Palpitation  of  the  Heart 428 

Tachycardia 429 

Bradycardia 430 

Arrhjrthmia 431 

Heart-block 432 

Angina  Pectoris 433 

-       DISEASES    OF    THE    ARTERIES 

Arteriosclerosis 435 

Aneurysm  of  the  Aorta 437 


CONTENTS  XV 

Page 

Aneurysm  of  the  Arch  of  the  Aorta 43^ 

Aneurysm  of  the  Thoracic  Aorta 44 1 

Aneurysm  of  the  Abdominal  Aorta 44 1 

DISEASES  OF  THE  RESPIRATORY  SYSTEM 

Physical  Diagnosis 44^ 

Association  of  the  Physical  Signs 464 

General  Symptomatology 4^4 

DISEASES    OF   THE    NASAL    PASSAGES 

Acute  Nasal  Catarrh 4^8 

Chronic  Nasal  Catarrh  . 471 

DISEASES    OF    THE    LARYNX 

Acute  Catarrhal  Laryngitis  ....    * 474 

Edematous  Laryngitis 47^ 

Spasmodic  Laryngitis 479 

Laryngismus  Stridulus 4^0 

Chronic  Laryngitis • 4^2 

Sj^philitic  Laryngitis 483 

Tuberculous  Laryngitis 483 

DISEASES    OF    THE   BRONCHIAL    TUBES 

Acute  Bronchitis 485 

Chronic  Bronchitis 489 

Fibrinous  Bronchitis 495 

Hay  Fever 497 

Asthma 500 

DISEASES    OF   THE   LUNGS 

Emphysema 5^4 

Hemoptysis 5^7 

Congestion  of  the  Lungs 5^9 

Edema  of  the  Lungs 5ii 

Bronchopneumonia 5^2 

Fibroid  Pneumonia 5^6 

DISEASES   OF   THE    PLEURA 

Pleurisy 5i6 

Hydrothorax 52J 

Pneumothorax 5^2 


XVI  CONTENTS 

DISEASES  OF  THE  NERVOUS  SYSTEM 

Page 

General  Symptomatology .   523 

DISEASES    OF    THE    CEREBRAL    MEMBRANES 

Pachymeningitis 533 

Acute  Leptomeningitis 535 

Tuberculous  Meningitis 538 

DISEASES    OF    THE    CEREBRUM 

Congestion  of  the  Brain 543 

Cerebral  Anemia 545 

Cerebral  Hemorrhage 547 

Cerebral  Thrombosis  and  Embolism ' 553 

Cerebral  Abscess 557 

Cerebral  Tumor • 559 

Aphasia ;    .    .    .    .  562 

Vertigo 564 

Migraine 567 

Acute  Hydrocephalus 570 

Congenital  Hydrocephalus 571 

DISEASES    OF    THE    SPINAL    CORD 

Spinal  Hyperemia 573 

Spinal  Pachymeningitis 575 

Spinal  Meningitis '. - 576 

Acute  MyeHtis 578 

Localization  of  the  Functions  of  the  Segments  of  the  Spinal  Cord    .  580 

Bulbar  Paralysis 582 

Progressive  Muscular  Atrophy 584 

Pseudo-Hypertrophic  Muscular  Paralysis 586 

Acute  Ascending  Paralysis 587 

Spinal  Sclerosis 587 

Amyotrophic  Lateral  Sclerosis 588 

Locomotor  Ataxia 589 

Ataxic  Paraplegia  . 593 

Cerebrospinal  Sclerosis 594 

Hereditary  Ataxia 596 

Differential  Diagnosis  of  Chronic  Diseases  of  the  Spinal  Cord  .    .    .597 

Syringomyelia.    . 597 

DISEASES    OF   THE   NERVES 

Simple  Neuritis 599 

Multiple  Neuritis 601 


CONTENTS  XVll 

Page 

Beri-beri 604 

Herpes  Zoster 604 

Neuralgia 606 

Neuralgia  of  the  Fifth  Nerve 606 

Cervico-occipital  Neuralgia  .    .    .    .' 607 

Cervico-brachial  Neuralgia 607 

Dorso-intercostal  Neuralgia 607 

Lumbo-abdominal  Neuralgia 607 

Sciatica 607 

Erythromelalgia '. 608 

Prognosis  and  Treatment  of  Neuralgia  in  General 608 

Facial  Paralysis 610 

Paralysis  of  the  Laryngeal  Muscles ...612 

GENERAL    NERVOUS    DISEASES 

Chorea 613 

Epilepsy 615 

Hysteria " 619 

Neurasthenia 623 

Raynaud's  Disease 624 

Occupation  Neuroses 625 

Paralysis  Agitans 626 

MENTAL  DISEASES 

General  Considerations 627 

Classification  of  Insanity 628 

Melancholia 629 

Mania 632 

Epileptic  Insanity 637 

Circular  Insanity 639 

Katatonia 639 

Delusional  Insanity    .    .    .• 641 

Paranoia 643 

General  Paralysis 644 

Dementia 648 

DISEASES  OF  THE  SKIN 

General  Symptomatology 652 

Anemia  of  the  Skin    .• 653 

Hyperemia  of  the  Skin 653 

INFLAMMATIONS    OF   THE    SKIN 

Erythema  Multiforme 654 

Erythema  Scarlatinoides 655 


XVlll  CONTENTS 

Page 

Erythema  Nodosum 656 

Erythema  Induratum 656 

Urticaria 657 

Angioneurotic  Edema 660 

Eczema 661 

Treatment  of  Special  Forms  and  Varieties  of  Eczema 672 

Eczema  Seborrhoicum 680 

Impetigo  Contagiosa 680 

Ecthyma 681 

Dermatitis  Herpetiformis 682 

Pemphigus 683 

Pompholyx 685 

Herpes  Simplex 685 

Lichen  Planus 687 

Prurigo 688 

Acne. 688 

Acne  Rosacea 693 

Sycosis  Vulgaris 695 

Psoriasis  .    .    .    .■ 696 

Pityriasis  Rosacea 700 

Dermatitis 700 

Furunculus 703 

Carbunculus 704 

PARASITIC   DISEASES 

Tinea  Circinata , 707 

Tinea  Tonsurans 709 

Tinea  Sycosis 712 

Tinea  Versicolor 714 

Tinea  Favosa 715 

Scabies 717 

Pediculosis 720 

HYPERTROPHIES   OF   THE   SKIN 

Lentigo 723 

Chloasma 724 

Callositas 726 

Clavus : 727 

Ichthyosis ' 728 

Verruca 730 

Molluscum  Epitheliale 732 

Comedo 732 

MiHum 734 


CONTENTS  XIX 

Page 

Sebaceous  Cyst 735 

Keratosis  Pilaris 735 

Hypertrichosis 735 

Elephantiasis 73^ 

Onychauxis 73^ 

ATROPHIES    OF   THE    SKIN 

Albinism 737 

Vitiligo 737 

Scleroderma 737 

Morphea ' 738 

Canities 738 

Atrophy  of  the  Nails 738 

Alopecia 738 

Alopecia  Areata 739 

NEW    GROWTHS    OF    THE    SKIN 

Keloid 740 

Xanthoma .• 740 

Lupus  Erythematosus 741 

Lupus  Vulgaris • 743 

Scrofuloderma 745 

DISORDERS    OF    SECRETION 

Hyperidrosis 745 

Anidrosis 748 

Sudamina 749 

Miliaria 749 

Seborrhea 751 

DISORDER   OF   SENSATION 

Pruritus 754 

Index 759 


THE 
PRACTICE  OF  MEDICINE 


INTRODUCTION 


The  practice  of  medicine  is  the  exercise  of  medical  art,  and  em- 
braces all  that  pertains  to  the  knowledge,  prevention,  and  cure 
of  those  departures  from  normal  to  which  the  term  disease  is  applied . 

Disease  may  be  organic  when  there  is  structural  change,  or  func- 
tional when  there  are  no  demonstrable  lesions.  It  is  questionable 
whether  these  forms  can  exist  independently. 

Pathology  is  the  study  of  disease.  It  explains  the  origin  and 
development  {pathogenesis),  causes  {etiology),  nature  {morbid  anat- 
omy), and  clinical  history  {morbid  physiology)  of  the  various  abnor- 
mal conditions  that  may  disturb  the  economy.  Pathology  is  said 
to  be:  (i)  general  when  it  is  concerned  with  the  study  of  morbid 
conditions  common  to  many  diseases,  (2)  special  when  it  is  restricted 
to  the  study  of  individual  diseases. 

Pathogenesis  is  that  subdivision  of  pathology  which  treats  of 
the  origin  and  development  of  morbid  processes  or  disease. 

Lesions  are  appreciable  anatomical  changes. 

Etiology  is  that  branch  of  general  pathology  which  considers 
the  causes  of  disease.  These  may  be  internal,  external,  ordinary, 
specific,  primary,  secondary,  predisposing,  and  exciting.  The  internal 
or  intrinsic  causes,  include  those  having  their  origin  in  the  mind 
such  as  prolonged  mental  application,  intense  or  long-continued 
emotional  excitement,  long-continued  mental  depression,  etc.,  and 
in  the  accumulation  of  certain  products  in  the  blood  as  the  result  of 
faulty  secretion  or  excretion,  or  the  absorption  of  ptomaines  from  the 
digestive  tract. 

The  external  or  extrinsic  causes,  embrace  traumatism  and  sub- 
stances introduced  into  the  body  from  without  such  as  poisons, 
bacteria,  toxins,  etc. 


2  INTRODUCTION 

The  ordinary  causes  are  those  to  which  we  are  constantly  exposed 
such  as  atmospheric  and  cHmatic  changes. 

The  specific  or  special  causes  are  in  nearly  every  instance  micro- 
.  organisms  (bacteria  or  protozoa) ;  many  varieties  of  which  are  capable 
of  producing  distinct  diseases,  for  example,  the  tubercle  bacillus  pro- 
ducing tuberculosis,  the  Comma  bacillus  causing  Asiatic  cholera, 
and  the  Plasmodium  malarice  (a  protozoon)  giving  rise  to  malaria. 
A  disease  produced  (or  supposed  to  be  produced)  by  a  specific  cause 
or  microorganism  is  said  to  be  infectious;  if  the  disease  is  communi- 
cable by  contact  it  is  spoken  of  as  contagious.  Infectious  diseases 
may  or  may  not  be  contagious  but  all  contagious  diseases  are  infec- 
tious. The  distinction  between  infectious  and  contagious  diseases 
is  not  of  much  importance  now. 

A  primary  cause  is  the  cause  in  which  the  affection  took  its  origin. 
Traumatism  is  a  common  primary  cause. 

A  secondary  cause  is  a  contributory  cause  and  the  term  is  usually 
applied  to  the  various  morbid  excretory  products  of  the  blood. 

The  predisposing  causes  embrace  any  inherited  or  acquired  suscepti- 
bility to  disease. 

An  inherited  predisposition  is  also  a  diathesis,  as  examples  of  which 
may  be  mentioned  the  rheumatic  and  tuberculous  diatheses. 

Acquired  predisposition  depends  upon  the  race,  sex,  age,  occupa- 
tion, habits,  and  environment  of  the  individual. 

The  exciting  causes  are  those  that  immediately  precede  and  pre- 
cipitate an  attack  of  any  disease.  The  influence  of  atmospheric 
changes  in  the  production  of  rheumatism  may  be  mentioned  as  an 
example. 

When  a  disease  is  found  in  a  certain  locaHty  more  or  less  con- 
stantly, it  is  said  to  be  endemic;  when  it  affects  a  very  large  part  of 
a  community,  it  is  said  to  be  epidemic;  when  it  is  present  in  very 
large  areas  at  a  time,  as  over  several  countries,  it  is  said  to  be  pan- 
demic; and  when  it  is  found  only  in  single  or  stray  cases  in  a  given 
locaHty,  it  is  said  to  be  sporadic. 

Morbid  anatomy  or  pathological  anatomy  is  that  division  of 
pathology  which  considers  the  structural  change  or  lesions  of  dis- 
ease. It  may  therefore  be  gross  or  microscopic  {histo pathology). 
Microscopic  morbid  anatomy  may  be  said  to  include  the  study  of 
the  tissues  (histology),  the  blood  (hematology),  and  the  various 
bacteria  (bacteriology). 

The  clinical  history  of  a  disease  includes  all  the  data  referable  to 


INTRODUCTION  3 

the  manifestations  of  the  disease  process,  or  its  morbid  physiology. 
It  embraces  the  symptomatology,  physical  signs,  complications,  sequels^ 
diagnosis,  prognosis,  treatment,  and  termination. 

S3miptomatology  is  the  study  of  the  various  symptoms  and  signs 
whereby  the  disease  is  detected.  They  may  be  objective,  when 
evident  to  the  senses  of  the  observer,  such  as  redness,  swelling,  high 
temperature,  etc.,  or  subjective  when  the  patient  alone  is  aware  of 
their  existence,  such  as  pain,  numbness,  vertigo,  and  nausea.  The 
earliest  recognizable  symptoms  are  called  the  prodromes. 

The  period  of  incubation  is  the  interval  that  exists  between  the 
entrance  of  a  poison  into  the  system  and  the  manifestations  of  its 
symptoms. 

Pathognomonic  symptoms  are  those  especially  indicative  of  cer- 
tain diseases  as,  for  instance,  the  rusty  sputum  of  pneumonia  and  the 
eruption  of  small-pox. 

An  acute  disease  is  one  in  which  the  invasion  is  sudden  and  rapid, 
and  as  a  rule  severe;  when  the  symptoms  develop  less  rapidly  and 
are  less  intense,  the  disease  is  said  to  be  subacute;  when  gradual  or 
slow  in  development,  of  longer  duration,  and  of  lessened  intensity, 
the  disease  is  said  to  be  chronic. 

The  physical  signs  are  objective  symptoms  and  are  elicited  by 
inspection,  mensuration,  palpation,  percussion,  and  auscultation. 

Complications  are  morbid  conditions  that  may  arise  in  the  course 
of  the  original  disease. 

The  sequels  of  a  disease  are  the  morbid  phenomena  which  remain 
as  the  result  of  disease. 

Diagnosis  of  disease,  or  the  discrimination  of  diseases,  implies 
a  complete,  exact,  and  comprehensive  knowledge  of  the  phenomena 
under  consideration,  as  regards  their  origin,  seat,  extent,  and  nature. 

A  direct  diagnosis  is  made  when  the  morbid  condition  is  revealed 
by  a  combination  of  clinical  phenomena,  or  some  one  or  more  pathog- 
nomonic symptoms. 

A  differential  diagnosis  is  the  result  when  the  diseases  resembling 
each  other  are  called  to  mind  and  eliminated  from  each  other, 

A  diagnosis  by  exclusion  is  made  by  proving  the  absence  of  all 
diseases  which  might  give  rise  to  the  symptoms  observed,  except 
one,  the  presence  of  which  is  not  actually  indicated  by  any  positive 
symptoms. 

The  prognosis  of  a  disease  is  the  conclusion  or  prediction  relating 
to  the  future  course  or  termination  of  the  affection  under  considera- 


4  INTRODUCTION 

tion,  or  the  art  of  making  such  predictions.     Like  diagnosis,  it  de- 
pends largely  on  clinical  experience. 

Treatment  of  disease  may  be  prophylactic  or  preventive;  and 
curative.  It  may  be  .  divided  into  hygienic,  dietetic,  and  medicinal 
treatment.  It  is  abortive  when  the  disease  is  checked  in  its  early 
stage,  expectant  when  the  affection  is  allowed  to  pursue  its  natural 
course,  palliative  when  the  object  is  only  to  relieve  suffering,  and 
restorative  when  it  aims  to  overcome  weakness  and  prostration. 

The  termination  of  a  disease  may  be  in  cure,  secondary  processes, 
or  death.  Cure  may  be  affected  by  a  slow  return  to  health  (lysis) 
or  abruptly  with  a  critical  discharge   (crisis). 

Secondary  processes  are  those  in  which  the  original  affection  is 
substituted  by  a  new  morbid  process,  as  in  the  case  of  endocarditis 
following  rheumatism. 

Death  may  be  brought  about  by  a  progressively  increasing  debility 
(asthenia),  as  in  phthisis,  cancer,  and  Bright's  disease;  by  an  insuffi- 
cient quantity  or  quality  of  the  blood  (anemia) ;  by  non-aeration  of 
the  blood  (apnea)  as  in  lung  affections  and  croup;  or  by  cerebral 
involvement  (coma)  as  is  seen  in  uremia,  narcotic  poisoning,  and 
apoplexy. 

Terminology.: — Words  ending  in  itis  indicate  inflammatory  con- 
ditions, such  as  peritonitis;  those  ending  in  rhcea  or  rhea  refer  to  the 
transudation  of  liquid  from  a  mucous  surface,  as,  for  example, 
diarrhea;  those  ending  in  algia  denote  painful  conditions  independent 
of  inflammation  as  gastralgia;  those  ending  in  cemia  or  emia  signify 
a  morbid  condition  of  the  blood,  as,  for  instance,  anemia;  those  end- 
ing in  uria  relate  to  abnormal  conditions  of  the  urine  as  albuminuria; 
while  those  terminating  in  oma  signify  a  tumor,  for  example  sarcoma 
and  carcinoma.  A  morbid  condition  of  a  part  without  any  indication 
of  its  nature  is  designated  by  the  suffix  pathy,  as  encephalopathy  and 
adenopathy. 

The  prefix  hydro  indicates  a  dropsical  condition,  as,  for  instance, 
hydroperitoneum;  the  preflx  pneumo  denotes  the  abnormal  presence 
of  air  in  a  part,  as  pneumothorax;  the  prefix  peri  refers  to  the  investing 
membrane  of  a  part,  thus  perinephritis  indicates  inflammation  of 
the  membrane  surrounding  the  kidney.  The  connective  tissue  sur- 
rounding a  part  is  designated  by  the  prefix  para  as,  for  example, 
parametritis,  the  term  for  inflammation  of  the  connective  tissue  sur- 
rounding the  uterus. 


FEVERS  5 

INFECTIOUS  DISEASES 

FEVERS 

Fever  is  a  condition  in  which  the  body  temperature  is  above  normal 
(98.6°F.)  and  which  is  attended  by  quickened  circulation  and  re- 
spiration, marked  tissue  changes  causing  proportionate  wasting  of 
the  body,  and  disordered  secretions  giving  rise  to  anorexia,  thirst, 
constipation,  and  scanty,  high-colored  urine  of  increased  specific 
gravity.  It  may  be  due  to  a  disorder  of  the  sympathetic  nervous 
system  inducing  disturbances  of  the  vaso-motor  filaments,  or  to  a 
derangement  of  the  nerve-centers  adjacent  to  the  corpus  striatum 
which  govern  heat  production,  distribution,  and  dissemination. 
Fever  may  be  said  to  result  from  a  disturbance  of  the  balance  which 
normally  exists  between  heat  production  and  heat  dissipation,  and' 
is  usually  toxemic  in  origin. 

Rise  of  temperature  (or  pyrexia)  is  the  most  prominent  feature 
of  all  fevers  and  can  be  accurately  determined  only  by  the  use  of  the 
clinical  thermometer  placed  in  the  mouth,  axilla,  rectum,  or  vagina. 
The  mouth  is  usually  selected  by  preference.  There  is  a  slight  varia- 
tion in  the  temperature  of  these  various  sites,  as  is  shown  in  the 
following  table: 

Axilla,  or  groin 98 . 4°F.  (36.9°C.) 

Mouth 98.6°F.  (37°C.) 

Rectum,  or  vagina 99.5°F.  (37.5°C.) 

Subnormal  Temperature. — A  fall  of  temperature  below  normal 
is  a  less  frequent  occurrence  but  may  be  observed  in  collapse, 
cholera,  convalescence  from  acute  febrile  diseases,  and  in  chronic 
affections  such  as  valvular  heart  disease,  myxedema,  diabetes, 
certain  nervous  diseases,  cancer,  etc. 

Degrees  of  Pyrexia : 

Feverishness 99°  to  ioo°F.    High  fever 104°  to  I05°F. 

Slight  fever 100°  to  ioi°P.    Intense  fever.  .  .    105°  to  io6°F. 

Moderate  fever.  .  .    101°  to  103 °F.    Hyperpyrexia.  . .    io6°F.  or  over. 

Fever  may  be  divided  into  three  stages:  invasion,  in  which  the 
temperature  gradually  rises;  fastigium  or  stadium,  in  which  its  acme 
is  reached  and  to  some  extent  maintained;  and  defervescence  or  de- 
cline, in  which  the  temperature  gradually  drops  until  it  becomes 
normal. 

The  decline  of  a  fever  may  be:     (i)  by  lysis,  in  which  the  tem- 


6  FEVERS 

perature  falls  gradually,  as  in  typhoid,  acute  rheumatism,  pleurisy, 
and  bronchopneumonia;  or  (2)  by  crisis,  in  which  it  drops  sud- 
denly and  is  attended  by  sweating  and  increased  flow  of  urine,  as 
in  erysipelas,  malaria,  measles,  pneumonia,  relapsing  fever,  and 
typhus  fever. 

Diurnal  variations  (usually  i°F.)  are  common  to  all  fevers.  In 
most  cases  the  highest  point  is  reached  in  the  early  part  of  the 
evening  (6  p.m.)  and  the  lowest  at  a  corresponding  hour  in  the  morn- 
ing (6  A.M.),  but  occasionally  this  order  is  reversed. 

Types. — Fever  may  be  considered  as  of  three  types,  continued, 
remittent,  and  intermittent.  In  continued  fever  the  diurnal  varia- 
tion is  seldom  more  than  one  or  one  and  a  half  degrees  F.  This  type 
is  seen  in  scarlet  fever,  pneumonia,  and  typhus  fever. 

In  remittent  fever,  the  diurnal  variation  is  greater  but  the  mini- 
mum temperature  never  reaches  the  normal  point.  This  variety 
is  observed  in  septic  conditions,  remittent  fever,  and  typhoid  fever. 

In  intermittent. fever,  the  diurnal  variation  is  very  marked  and 
the  temperature  drops  to  normal  or  below.  As  examples  of  this 
type  may  be  mentioned  the  septic  fevers,  intermittent  malaria, 
relapsing  fever,  and  the  fever  associated  with  impacted  gall-stones. 

Some  fevers  are  characterized  by  but  one  intermission  or  re- 
mission. For  instance,  variola  has  a  remission  on  the  third  day, 
measles  has  a  fall  of  temperature  on  the  third  or  fourth  day  with 
a  subsequent  rise,  dengue  has  an  intermission  on  the  third  or  fourth 
day  which  may  extend  over  forty-eight  or  seventy-two  hours,  and 
yellow  fever  has  an  intermission  on  the  third  or  fourth  day. 

The  pulse  usually  bears  a  direct  relation  to  the  temperature  and 
in  most  cases  a  rise  of  i°F.  is  attended  by  an  increase  of  8  to  10 

beats  of  the  pulse  per  minute.     Thus: ' 

___^_^— ^^_— — — .^— ^^— ^ 

A  temperature  of:  !        Corresponds  to  a  pulse  of: 


98°F.  or  36.7°C. 

99°F.  or  37.2°C. 
ioo°F.  or  37.8°C. 
ioi°P.  or  38.4°C. 
I02°F.  or  38.9°C. 
I03°F.  or  39.S°C. 
I04°F.  or  40  °C. 
i05°F.  or  40.S°C. 
io6°F.  or  4i.i°C. 


60 

70 

80 

90 

100 

no 

120 

130 

140 


Note. — This  relation  does  not  hold  good  in.  Yellow  fever  after  the 
first  few  days;  in  this  disease  the  temperature  remains  high,  while  the 
pulse  declines  to  50  or  even  40  per  minute. 


FEVERS 


General  Treatment  of  all  Fevers. — All  patients  with  fever  should 
be  placed  at  rest  in  bed  in  a  moderately  heated,  quiet,  and  well- 
ventilated  room;  and,  if  possible,  a  sensible  and  well-trained  nurse 
should  be  employed.  The  patient  should  be  nourished  by  the 
administration  of  milk,  beef-tea,  animal  broths,  and  peptonized 
or  other  highly  nutritious  food  in  small  quantities  at  frequent  but 
regular  intervals.  Solids  should  be  interdicted.  The  secretions 
should  be  rendered  free  by  the  administration  of  laxatives,  diuretics, 
and  diaphoretics.     Plenty  of  pure  cold  water  should  be  given. 

The  temperature  may  be  reduced  by  hydrotherapy  or  drugs. 
Hydrotherapy  includes  the  cold  pack,  the  cold  bath,  and  sponging. 
The  drugs  employed  to  reduce  temperature  are  quinine,  antipy- 
rine,  antifebrin,  and  phenacetin,  but  their  depressing  action  renders 
them  somewhat  dangerous,  with  the  exception  of  the  first  named; 
and  the  tendency  is  now  more  and  more  toward  hydrotherapy  and 
less  and  less  toward  drugs  (particularly  the  coal-tar  derivatives). 

Sudden  Onset. — A  high  fever,  rapidly  reached,  is  found  in  ton- 
sillitis, malaria,  scarlet  fever,  pneumonia,  osteomyelitis,  and  gas- 
trointestinal disturbances  in  children. 

The  incubatibn  period  varies  greatly  in  the  different  diseases, 
as  may  be  seerl  from  the  following  table  modified  from  that  given 
by  G.  H.  Roger  in  his  ''Introduction  to  the  Study  of  Medicine:" 


Minimum 


Maximum 


Average 


Anthrax 

Bubonic  plague 

Chancre  (hard),  see  Syphilis 

Chancre  (soft) 

Cholera 

Diphtheria 

Erysipelas 

Glanders 

Gonorrhea 

Hydrophobia 

Influenza 

Malaria 

Measles 

Mumps 

Recurrent  fever 

Rubella,  Rubeola, 
Rotheln 

Scarlatina 

Small-pox 

Syphilis 

Tetanus 

Typhoid  fever. . .  . 

Typhus 

Vacpinia 

Varicella 

Whooping  cough . 
Yellow  fever 


1  day 

2  days 

I  day 

1  day 

2  days 

3  hours 

24  hours 

I  (?)  to  2  days 
13  days 

1  day 

99  hours 

4  days 

7  days 

86  hours 

5  days 

7  hours 

7  days 

10  days 

2  hours 

2  days  (?) 

0  (?) 

2  days 

13  days 

2  days 

2^days 


3  days. 
7  days. 


3  days 

6  days 

IS  days. . ., 

22  days. . ." 

3  months 

I  to  several  weeks. .  . 

18  mos.  to  3  yrs.  (?)  . 

5  days 

Several  months 

14  days 

30  days 

8  days 

21  days 

7  weeks 

15  days. 

SO  days 

3S  days 

21  days 

23  days 

7  days 

19  days 

8  days 

6  days 


2  days. 

4  to  6  days. 

1  to  2  days. 

2  to  4  days. 

2  days. 

4  to  6  days. 

3  to  S  days. 
3  to  s  days. 
20  to  60  days. 
3  to  4  days. 

6  to  10  days. 
9  days. 
15  days. 

5  to  6  days 

18  days.y  - 

2  to  s  days. 
12  days. 

20  to  30  days. 

2  to  3  days. 
14  days. 

21  days. 

3  days. 

14  to  IS  days. 

8  days. 

3  to  4  days. 


FEVERS 


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SIMPLE    CONTINUED   FEVER  •      9 

Eruptive  Fevers. — Certain  fevers  are  attended  by  eruption,  the 
character  and  date  of  the  appearance  of  which  are  of  extreme  im- 
portance in  the  diagnosis. 

The  eruptive  fevers,  or  diseases  that  have  a  characteristic  rash 
are  called  the  Exanthemata.  The  foregoing  table  (modified  from  one 
in  Gould  and  Pyle's  Cyclopedia  of  Medicine  and  Surgery)  will  be  of 
service . 

Immimity.— Some  of  the  infectious  fevers  confer  protection 
against  subsequent  attacks;  among  which  may  be  mentioned  Ger- 
man measles,  measles,  mumps,  scarlet  fever,  small-pox,  typhus, 
varicella,  and  yellow  fever.  Second  attacks  occasionally  occur  in 
measles,  small-pox,  t^'phoid,  and  typhus  fever.  The  rest  of  the 
fevers  seem  devoid  of  immunizing  properties. 

Jaundice. — Occasionally  the  disturbance  of  metabolism  and  tissue 
change  are  so  great  in  fever  as  to  interfere  with  the  functional 
activity  of  the  liver  and  a  generalized  yellowish  discoloration  or 
jaundice  results.  This  is  common  in  acute  yellow  atrophy  of  the 
liver,  yellow  fever,  relapsing  fever,  and  intermittent  malaria. 

SIMPLE  CONTINUED  FEVER 

Synonjrms. — Febricula;  ephemeral  fever. 

Definition. — An  acute,  non-contagious,  febrile  disease  of  short 
duration  and  mild  type  unattended  by  characteristic  lesions.  When 
the  condition  lasts  only  one  day  it  is  called  ephemeral  fever;  the 
other  names  are  applied  to  cases  of  longer  duration. 

Etiology. — It  is  most  common  in  childhood  and  may  arise  from 
gastrointestinal  disorders,  mental  or  ph\'sical  fatigue,  excitement, 
emotion,  or  exposure  to  high  degrees  of  heat  or  cold. 

Symptoms. — The  onset  is  sudden  and  may  be  ushered  in  with 
nausea,  vomiting,  convulsions,  or  a  chill.  It  is  attended  by  great 
lassitude.  The  temperature  rises  suddenly  to  102°  or  io3°F.  and 
is  accompanied  by  headache,  increased  respiration,  quick  tense 
pulse,  dryness  of  the  skin,  thirst,  coated  tongue,  constipation,  and 
scanty,  high-colored  urine  of  increased  specific  gravity.  Delirium 
may  be  present  in  some  cases.  There  is  no  constant  or  character- 
istic eruption  but  herpes  are  often  observed  on  the  lips.  The  dura- 
tion of  the  affection  varies  from  twenty-four  hours  to  six  or  seven 
days  and  may  terminate  b}^  crisis  or  Ij^sis.     Convalescence  is  rapid. 

Diagnosis. — The  history  is  always  of  value  in  differentiating 
this   condition   from   other   somewhat   similar   affections,    as   most 


lO  .  INFLUENZA 

cases  are  observed  in  children  as  the  result  of  mild  gastrointestinal 
trouble.  Local  inflammatory  conditions  should  be  carefully  ex- 
cluded by  a  thorough  examination.  The  concomitant  symptoms 
will  aid  in  distinguishing  it  from  atypical  cases  of  typhoid  fever; 
while  in  malaria,  the  periodicity  and  the  presence  of  the  Plasmodium 
will  settle  the  diagnosis. 

Prognosis. — Uneventful  recovery  is  the  rule. 

Treatment. — Rest  in  bed  and  a  liquid  or  semisolid  diet  are  essen- 
tial. If  due  to  gastrointestinal  disturbances  a  powder  containing 
calomel,  gr.  3^  (o.oi  gm.),  sodium  bicarbonate,  gr.  ij  (0.13  gm.), 
and  powdered  ipecac,  gr.  3^2  (o-ooS  gm-)?  should  be  taken  every 
two  hours  until  twelve  have  been  consumed  after  which  an  enema 
or  a  seidlitz  powder  should  be  given.  The  body  surface  should  be 
sponged,  and  diaphoretics  and   diuretics  should  be  administered. 

I^.     Liq.  ammonii  acetatis Biij  90  c.c. 

Spts.  ^theris  nitrosi 5vj  24  c.c. 

Potassii  citratis 5iv  16  c.c. 

Aquae menthse piperitae  q.  s.  ad..    Bvj        180  c.c. 
M.  S. — One  tablespoonful  every  four  hours. 

Acetanilide,  gr.  ij  to  v  (0.13  to  0.3  gm.),  may  be  given  every  two 
or  three  hours  in  cases  unassociated  with  digestive  disorders.  Tinc- 
ture of  aconite  may  be  employed  when  the  pulse  is  quick.  When 
the  nervous  symptoms  and  insomnia  are  marked  potassium  bro- 
mide or  trional  may  be  used.  During  convalescence  quinine  and 
tincture  of  nux  vomica  are  of  great  value. 

INFLUENZA 

Synonyms. — ^La  grippe;  grip;  epidemic  catarrh;  catarrhal  fever. 

Definition. — An  acute,  infectious  and  contagious  disease;  sporadic, 
epidemic,  and  pandemic;  associated  with  catarrhal  inflammation 
of  the  respiratory  and  sometimes  of  the  digestive  tract,  muscular 
pain,  disturbances  of  the  nervous  system  and  debility  out  of  all 
proportion  to  the  intensity  of  the  fever  and  the  catarrhal  processes, 
and  a  tendency  toward  serious  complications  and  sequels.  There 
are  no  characteristic  anatomical  lesions. 

The  disease  was  almost  unknown  until  the  appearance  of  the 
pandemic  in  the  winter  of  1889-90. 

Causes. — The  affection  is  induced  by  an  extremely  small,  non- 
motile  microorganism,  the  bacillus  of  Pfeifer  which  is  readily  ob- 


INFLUENZA  1 1 

tained  from  the  sputum.  The  manner  in  which  it  produces  the 
disease  is  not  well  understood.  One  attack  seems  to  predispose  to 
subsequent  attacks.  It  usually  occurs  in  epidemics  along  the  lines 
of  traffic. 

S3miptoms. — There  may  be  an  incubation  period  of  a  few  days, 
but  often  the  onset  is  sudden  with  a  chill  or  chilliness  followed  by 
fever,  the  temperature  reaching  ioi°  to  io3°F.,  a  quick,  compressible 
pulse,  severe  shooting  pains  in  the  eyes  and  forehead,  and  neuralgic 
pains  in  the  joints  and  muscles.  These  symptoms  are  followed  by 
chilliness  along  the  spine,  pain  in  the  throat,  hoarseness,  deafness, 
coryza,  sneezing,  injected  and  watery  eyes,  and  dry  irritative  cough. 
The  tongue  is  usually  furred  and  anorexia,  nausea,  epigastric  distress, 
vomiting,  and  sometimes  diarrhea  are  present.  Depression  and  de- 
bility disproportionate  to  the  symptoms  are  almost  constant.  The 
symptoms  usually  group  themselves  so  that  an  attack  may  be  said 
to  be  of  the  catarrhal,  gastrointestinal,  or  nervous  type  according 
to  which  group  predominates.  Any  of  these  symptoms  may  be 
greatly  exaggerated,  causing  the  affection  to  simulate  other  febrile 
diseases.  In  mild  cases  the  temperature  falls  on  the  fourth  or  fifth 
day  by  crisis,  and  convalescence  promptly  begins  in  the  absence  of 
complications.  Complications  and  relapses  are  common  and  fre- 
quently prolong  the  disease  over  several  weeks. 

Complications  and  Sequels. — Inflammatory  conditions  of  the 
respiratory  tract  (pneumonia,  bronchopneumonia  and  bronchitis) 
are  the  most  frequent.  Hyperpyrexia,  cerebrospinal  meningitis, 
nephritis,  pericarditis,  and  cardiac  neuroses  are  also  encountered  as 
complications.  As  sequels  may  be  mentioned  phthisis,  mania,  con- 
fusional  insanity,  melancholia,  neurasthenia,  insomnia,  neuritis, 
neuralgia,  persistent  headache,  and  lymphatic  enlargements. 

Diagnosis. — In  order  to  recognize  influenza,  the  sudden  onset, 
marked  general  catarrh,  the  severe  pains  and  pronounced  prostra- 
tion should  be  borne  in  mind.  In  the  presence  of  an  epidemic  there 
will  be  but  little  difficulty.  Isolated  cases  may  be  mistaken  for 
acute  bronchitis,  typhoid  fever,  dengue,  or  cerebrospinal  fever,  but 
the  presence  of  the  cardinal  symptoms  will  serve  to  make  the 
distinction. 

Prognosis. — Recovery  is  the  rule  in  young  and  healthy  adults 
and  may  be  looked  for  in  uncomplicated  cases.  In  either  extreme 
of  life  the  disease  becomes  proportionately  more  grave.  The  pres- 
ence of  chronic  organic  diseases,   such  as  Bright's  disease,  fatty 


12  INFLUENZA 

heart,  emphysema,  and  tuberculosis,  influence  the  affection  un- 
favorably.    Many  die  of  the  complications. 

Treatment. — Supportive  measures  are  indicated  from  the  start 
to  combat  the  marked  exhaustion.  The  patient  should  be  placed 
at  absolute  rest  in  bed  and  restricted  to  a  semi-solid  diet.  All  the 
secretions  should  be  disinfected.  The  bowel  movements  should  be 
kept  soluble,  preferably  by  the  administration  of  fractional  doses  of 
calomel.  In  the  early  stages  a  hot  foot-bath  or  a  hot  tub-bath  to- 
gether with  the  administration  of  sweet  spirit  of  niter  or  the 
solution  of  ammonium  acetate  may  often  be  of  great  benefit  (see 
prescription  on  page  lo). 

The  catarrhal  symptoms  and  pains  are  often  reHeved  by  the 
following : 

I^.     Phenacetin gr.  iij  0.2      gm. 

Pulv.  camphorae gr.  j  o .  065  gm. 

Caffein.  citrat gr.  j  o. 065  gm. 

M.  Disp.  in  capsul.  vel  chart.     No.  j. 

S. — To  be  given  every  two  hours  alternated  with  quinine  sul- 
phate gr.  ij  (0.13). 
Or— 

I^.     Sodii  benzoat gij  8.0      gm. 

Salol 5ss,  2.0      gm. 

Phenacetin gr.  xl  2.6      gm. 

Strych.  sulphat gr.  ?:5         o  •  012  gm. 

M.     Disp.  in  chart,  vel  capsul.     No.  xij. 
S. — One  every  three  or  four  hours. 

Antipyrine,  salicin  (R.  G.  Curtin),  and  quinine  sulphate  when 
administered  during  the  very  early  stages  may  serve  to  abort  the 
disease  but  should  be  carefully  guarded  to  avoid  intensifying  the 
depression.  In  neuralgic  cases  the  salicylate  of  cinchonidine  in 
doses  of  gr.  v  (0.32  gm.)  every  four  hours  is  especially  valuable. 
Opium  in  some  form  may  be  necessary  in  severe  cases  to  relieve  the 
pains. 

An  excellent  prescription  is  the  following: 

I^.     Quininae  sulphat gr.  xxxvj  2  .25  gm. 

Extr.  aconiti gr.  ijss  0.16  gm. 

Phenacetin S  j  4.0    gm. 

Pulv.    Dover gr.  xij  o. 75  gm. 

M.  Ft.  in  capsul.  No.  xxiv. 

S. — Take  two  every  three  hours. 


INFLUENZA  1 3 

The  frequent  inhalation  of  the  vapor  from  a  pint  of  boiHng  water 
to  which  f§ss  (2  c.c.)  of  compound  tincture  of  benzoin  has  been 
added  reHeves  the  nasopharyngeal  and  bronchial  symptoms,  but 
should  they  become  troublesome  the  following  mixture  is  advised: 

I^.     Ammon.  chlorid gr.  x  0.65  gm. 

Tr.  hyoscyam TTlxv  i  .0    c.c. 

Syr.  ipecac lUv  0.3    c.c. 

Spts.  frumenti f  5 ss .  .  .  .  2.0    c.c. 

Aquas  chloroformi f  3 jss  6.0    c.c. 

M.  S. — To  be  taken  in  water  every  three  or  four  hours. 

The.  complication  of  pneumonia  is  best  combated  by  the  use  of 
stimulants  such  as  alcohol  and  strychnine.  The  following  prescrip- 
tion is  also  recommended  (Pepper) : 

I^.     Morphinae  sulphat gr.  j  o .  065  gm. 

Quininas  sulphat gr.  xxxv  2 . 3      gm. 

Strychninas  sulphat gr.  ss  o .  03    gm. 

Acid.  phos.  dil f  3iij  12.0      c.c. 

Glycerini f 5v  20.0      c.c. 

Aquae q.  s.  ad  f  §iij  q.  s.  adQO.o      c.c. 

M.  S. — A  teaspoonful  four  to  six  times  daily,  in  water. 

In  case  the  quinine  adds  to  the  patient's  discomfort,  the  following 
prescription  may  be  found  beneficial.  First  give  a  mercurial  purge, 
and  then. 

I^.     Sodii  salicylatis gr.  x  o .  65  gm. 

Potassii  bicarbonatis gr.  x  •           0.65  gm. 

Tinctura  nucis  vomicae TTlx  o .  65  c.c. 

Aquae  chloroformi.  .  .q.  s.  ad  f  §j  ad  30.0    c.c. 
M.  S. — Take  every  four  hours. 

Bartholow  advises  the  early  use  of  pilocarpine,  gr.  }/q  (0.0 i  gm.), 
repeated  until  its  mild  physiological  effects  ensue  when  it  is  substi- 
tuted by  duboisine,  gr.  j^^oo  "to  }ioQ  (0.00022  to  0.00032  gm.),  twice 
daily;  and  for  the  depression  he  employs  the  official  pills  of  the 
iodide  of  iron,  one  pill  every  four  hours,  and  has  the  patient  inhale  one 
or  two  drops  of  pyridine  every  three  or  four  hours. 

During  convalescence  good  food,  and  tonics  such  as  strychnine, 
syrup  of  the  iodide  of  iron,  quinine,  cod  liver  oil,  etc.,  should  be 
freely  given  with  the  view  of  preventing  complications  and  sequels 
which,  when  they  do  occur,  receive  the  same  treatment  as  if  they  were 
independent  affections. 


14  TYPHOID   FEVER 

TYPHOID  FEVER 

Synon3mis. — Enteric  fever;  gastric  fever;  nervous  fever;  entero- 
mesenteric  fever;  abdominal  typhus;  autumnal  fever. 

Definition. — An  acute,  infectious,  febrile  affection,  due  to  a  special 
poison;  characterized  by  insidious  prodromes,  epistaxis,  dull  head- 
ache followed  by  stupor  and  delirium,  red  tongue,  becoming  dry, 
brown,  and  cracked,  abdominal  tenderness,  early  diarrhea  and 
tympany,  and  a  peculiar  eruption  upon  the  abdomen;  rapid  prostra- 
tion and  slow  convalescence;  a  constant  lesion  of  Peyer's  patches, 
the  mesenteric  glands,  and  the  spleen  with  enlargement  of  the  latter. 

Causes. — The  predisposing  causes  are  early  adult  life  (fifteen  to 
thirty  years),  late  summer  and  early  fall  months,  fatigue,  and  indi- 
vidual susceptibility. 

The  exciting  cause  is  the  typhoid  bacillus  or  bacillus  of  Eberth, 
which  is  found  in  the  lesions,  blood,  stools,  urine  and  sputum  of 
typhoid  patients.  The  poison  gains  entrance  to  the  system  through 
the  alimentary  tract  by  means  of  contaminated  water,  milk,  ice, 
meat,  oysters,  celery,  lettuce  or  similar  substances.  Carelessness 
in  disposing  of  the  excreta  is  a  frequent  cause  but  flies  may  aid  in 
the  dissemination  of  the  poison.  The  atmosphere  is  never  impreg- 
nated with  the  fever  germ.  "Food,  fingers  and  flies"  are  the  chief 
means  of  local  propagation.     For  '' typhoid  carriers,"  see  page  22. 

Pathological  Anatomy. — The  anatomical'  lesions  of  typhoid 
fever  are  invariably  present  and  are  characteristic.  They  consist 
in  changes  in  Peyer's  patches,  solitary  glands  and  mesenteric  glands 
and  spleen,  and  may  be  divided  into  four  stages: 

First.  Stage  of  infiltration  or  swelling  due  to  excessive  prolifera- 
tion of  the  cellular  elements  and  infiltration  which  also  involves  the 
surrounding  mucous  membrane.  Peyer's  patches  become  pale, 
thickened,  hardened,  and  elevated  above  the  mucous  membrane. 
These  changes  may  affect  only  three  or  four  of  the  glands  or  may 
involve  the  entire  number.  They  have  been  noted  as  early  as  the 
second  day. 

Second.  Stage  of  necrosis,  softening,  or  sloughing  of  the  diseased 
structures.  The  exudate  may  be  absorbed  or  it  may  undergo  ne- 
crotic changes  and  be  discharged  leaving  an  oval  ulcer  with  an  irregular 
margin  having  for  its  base  the  submucous,  muscular,  or  peritoneal 
coat  of  the  intestine.  These  changes  take  place  in  the  second  or 
third  week  of  the  disease. 


TYPHOID   FEVER  1 5 

Third.  Stage  of  ulceration,  in  which  the  separation  of  the  slough- 
ing and  necrotic  areas  is  complete  leaving  ulcers  of  various  sizes 
at  the  sites  of  the  Peyer's  patches  and  solitary  glands.  This  process 
belongs  usually  to  the  third  week  of  the  disease.  These  ulcers  of  the 
intestine  are  characteristic,  and  can  be  differentiated  from  tuber- 
culous ulcers  in  the  same  situation,  as  follows: 

In  the  typhoid  ulcer  (i)  the  main  axis  of  the  ulcer  lies  parallel 
with  that  of  the  intestine;  (2)  it  lies  opposite  to  the  mesenteric 
attachment;  (3)  it  has  smooth  floor  and  undermined  edges;  (4)  it 
commonly  leads  to  perforation.  In  tuberculous  ulcer  (i)  the  long 
axis  of  the  ulcer  lies  at  right  angles  to  that  of  the  intestine;  (2)  it  is 
not  necessarily  situated  opposite  the  mesenteric  attachment;  (3)  its 
floor  is  not  smooth  nor  are  its  edges  undermined,  but  rather  funnel- 
shaped  and  irregular;  (4)  it  is  not  apt  to  perforate,  but  it  does  not 
tend  to  heal,  rather  to  spread. 

Fourth.  Stage  of  cicatrization,  in  which  the  ulcerated  area  is 
replaced  by  scar-tissue.     The  gland-structure  is  never  regenerated. 

In  unfavorable  cases  perforation  is  liable  to  occur  at  this  stage. 
Under  ordinary  circumstances  this  stage  is  associated  with  the 
fourth  week. 

The  mesenteric  glands  and  spleen  undergo  changes  similar  to 
those  in  Peyer's  patches,  namely,  infiltration,  enlargement,  and 
softening,  but  they  seldom  if  ever  rupture  or  ulcerate.  The  spleen 
usually  begins  to  enlarge  in  the  middle  of  the  first  week,  the  enlarge- 
ment reaching  its  height  at  the  end  of  the  second  week. 

The  mucous  membrane  of  the  entire  intestinal  tract  is  the  seat  of 
catarrhal  changes  and  a  similar  condition  is  common  in  the  respira- 
tory tract.  The  heart,  liver,  and  kidneys  are  affected  with  parenchy- 
matous or  granular  changes. 

In  mild  cases  the  entire  exudate  in  the  lymphatic  aggregations  is 
absorbed  without  ulceration  and  in  very  rare  instances  the  disease 
may  manifest  itself  as  a  general  septic  infection  without  any  ana- 
tomical lesions  in  the  intestine. 

Symptoms.  Stage  of  Prodromes. — The  onset  is  insidious,  with  a 
feeling  of  general  malaise,  vertigo,  headache,  particularly  occipital 
pain,  disordered  digestion,  disturbed  sleep,  epistaxis,  depression, 
and  muscular  weakness,  followed  by  a  chill  or  chilliness,  the  patient 
being  unable  to  designate  the  day  on  which  the  symptoms  began. 
In  rare  instances,  the  disease  begins  abruptly  with  a  chill,  followed 
by  a  high  fever;  that  is  particularly  the  case  in  malarial  districts. 


i6 


TYPHOID   FEVER 


The  exact  duration  of  these  premonitory  symptoms  is  not  known, 
and  may  be  said  to  vary  from  a  few  days  to  two  or  more  weeks. 

First  week,  dates  from  the  onset  of  the  fever,  when  there  are  present 
increasing  temperature,  frequent  pulse,  headache,  Hstlessness,  the 
eyes  closed  as  in  sleep,  coated  tongue,  nausea,  diarrhea  (there  may  be 
constipation),  the  abdomen  moderately  distended  and,  upon  pres- 
sure in  the  right  iliac  fossa,  gurgling  sounds  and  tenderness.     Upon 


Fig.  I. — Clinical  chart  of  enteric  fever  of  four  weeks'  duration,  wittiout  complications, 
which  shows  the  temperature  curve  as  uninfluenced  by  treatment.  {From  Wilcox's 
Fever  Nursing.) 

jt 

the  seventh  day  a  few  reddish  spots  resembling  flea  bites  appear  upon 
the  abdomen,  chest,  or  back. 

Second  Week.  The  foregoing  symptoms  are  exaggerated;  fever 
'  now  continuous,  with  a  frequent  compressible,  dicrotic  pulse, 
tympanitic,  tender  abdomen,  gurgling  in  the  right  iUac  fossa,  nocturnal 
delirium,  severe  and  constant  headache,  often  stupor,  a  short  cough 
with  distinct  bronchial  rales  on  auscultation,  irregular  muscular  con- 
tractions {subsultus  tendinum),  sordes  upon  the  teeth  and  lips,  the 


k 


TYPHOID   TEVER  1 7 

tongue  losing  its  coating  and  becoming  more  or  less  dry,  the  diarrhea 
continuing.  During  this  stage  deafness  frequently  develops,  often 
increasing  until  profound,  and  persisting  in  convalescence.  Dis- 
turbances of  vision  are  common  in  pronounced  cases.  The  spleen 
is  increased  in  size. 

Third  Week.  Fever  changes  from  continuous  to  remittent;  the 
evening  exacerbations  continue  as  high  as  the  preceding  week,  the 
morning  fall  growing  more  decided  each  day,  but  all  the  other  symp- 
toms remain  about  the  same  until  near  the  end  of  the  week,  when  a 
marked  amelioration  begins. 

In  a  fair  proportion  of  cases  all  the  symptoms  grow  worse  toward 
the  end  of  the  second  or  during  the  third  week.  The  prostration  is 
extreme,  the  stupor  so  marked  that  it  is  hardly  possible  to  rouse  the 
patient,  the  tongue  is  dry,  hard,  cracked,  and  covered  with  a  brown 
crust ;  sordes  collect  on  the  gums  and  teeth ;  the  lips  are  cracked ;  the 
pulse  is  rapid  and  feeble;  the  respirations  shallow  and  quickened,  and 
there  may  be  retention  of  urine,  which  may  contain  albumin.  The 
stools  are  often  voided  involuntarily,  and  bed-sores  develop,  this 
condition  terminating  in  death  or  passing  thus  into  the  fourth  week. 

Fourth  Week.  The  fever  decidedly  remits,  and  is  almost  normal 
in  the  morning;  the  pulse  becomes  less  frequent  and  more  full, 
tongue  gradually  becoming  clean;  the  abdomen  lessens  in  size,  the 
diarrhea  ceases,  the  patient  passing  into  a  slow  convalescence, 
greatly  emaciated,  which  convalescence  may  continue  for  several 
weeks. 

Analysis  of  Symptoms. — The  temperature  record  of  typhoid  fever  is 
characteristic.  The  fever  on  the  morning  of  the  first  day  may  be 
stated  as  98°F.,  evening  100.5°;  second  morning  99. 5^  evening 
101.5°;  third  morning  100.5°,  evening  102.5°;  fourth  morning  101.5° 
evening  103.5°;  fifth  evening  104.5°.  From  that  time  until  the  end 
of  the  second  week  the  evening  temperature  ranges  between  103° 
and  105°,  the  morning  temperature  being  a  degree  or  more  lower 
During  the  second  or  third  week  hyperpyrexia,  or  fever  above  io5°F., 
may  develop,  and  adds  to  the  gravity  of  the  attack.  A  high  tem- 
perature during  the  third  and  fourth  week  is  of  grave  import.  Tem- 
peratures of  io6°-io7°  with  recovery  have  been  reported  but  are 
extremely  rare. 

Afebrile  cases  of  typhoid  fever  are  occasionally  observed;  all  other 
symptoms  (including  the  prostration)  excepting  the  step-like  tem- 
perature, being  present. 


1 8  TYPHOID   FE\TER 

Diarrhea  is  the  principal  intestinal  symptom;  if  absent,  the  lesion 
may  be  slight.  The  stools  are  at  first  dark,  but  early  in  the  second 
week  they  become  fluid,  offensive,  ochre-yellow  in  color,  resembhng 
''peasoup,"  and  may  be  streaked  with  blood.  They  number  from 
three  to  fifteen  during  the  twenty -four  hours. 

Constipation  occtirs  more  frequently  than  is  supposed. 

The  urine  has  the  ordinary  febrile  characters.  Typhoid  bacilli 
are  demonstrable  in  about  20  per  cent,  of  cases.  Retention  is 
common.  Ehrlich  describes  a  reaction  (diazo-reaction)  which  he 
believes  is  rarely  met  with  save  in  typhoid  fever;  but  it  has  been 
found  in  a  number  of  other  conditions,  particularly  those  having 
gastrointesinal  symptoms.  For  the  performance  of  this  test  see 
page  322. 

The  eruption  is  almost  constant.  It  consists  of  from  five  to  twenty 
small  rose-colored  spots  on  the  abdomen,  chest,  or  back,  sometimes 
on  the  Hmbs,  appearing  in  crops,  lasting  about  five  days,  disappearing 
on  pressure  and  at  death.  It  returns  with  relapses.  Eruption 
day  varies  from  the  seventh  to  the  ninth.  Rarely,  spots  of  delicate 
blue  tint — ^the  "taches  bleudtres'^  of  French  authors — are  observed. 
Very  occasionally  in  maUgnant  cases  the  eruption  may  become  hem- 
orrhagic or  petechial  in  character. 

Nervous  symptoms  are  pronounced  headache,  followed  by  duUness 
of  intellect,  passing  into  drowsiness  and  stupor,  with  great  prostration. 
Deafness  is  pronounced.  Sight  is  impaired,  and  in  grave  cases 
double  vision  results.  Delirium,  low  and  muttering,  generally 
pleasant  in  character,  is  nearly  always  present  in  severe  cases. 
Coma  vigil  is  a  grave  symptom,  the  patient  lying  perfectly  quiet 
with  eyes  open,  taking  no  heed  to  his  surroundings. 

Splenic  enlargement  is  an  almost  constant  clinical  feature.  A 
vertical  dullness  exceeding  two  ribs  and  an  interspace  signifies 
enlargement.  Palpation  is  a  valuable  aid  for  determining  splenic 
enlargement. 

Muscular  sy^nptoms  are  developed  late  in  the  second  or  early 
in  the  third  week,  and  consist  of  irregular  contractions,  carphologia 
(picking  at  the  bedclothes  or  at  imaginary  objects),  or  suhsultus 
tendinum  (see  page  16),  and  are  the  result  of  the  great  debility. 
The  reverse  of  muscular  contractions,  when  the  patient  lies  perfectly 
motionless  in  bed,  attempting  no  muscular  effort  of  any  kind,  is  a 
grave  sign. 

Convalescence  shows  great  debility  and  emaciation,  extreme  anemia, 


TYPHOID   FEVER  1 9 

and  severe  nervousness,  often  very  protracted.  It  is  during  con- 
valescence that  irritability  of  the  heart,  profuse  night-sweats,  insom- 
nia, and  in  women  loss  of  hair  occur. 

Complications. — Intestinal  hemorrhage  is  the  most  frequent  and 
at  times  the  most  critical  of  any  of  the  complications  of  typhoid 
fever.  The  hemorrhage  may  occur  any  time  between  the  fourteenth 
and  twentieth  day;  a  sudden  decline  of  the  temperature  to  the  nor- 
mal or  below  frequently  precedes  the  passage  of  blood  by  stool. 
The  hemorrhage  is  due  to  the  erosion  of  a  vessel  during  the  ulcera- 
tive stage. 

Perforation  makes  the  case  almost  hopeless.  It  is  attended  by 
sudden  localized  pain  and  tenderness,  tympanites,  abrupt  fall  in 
the  temperature,  and  symptoms  of  peritonitis  {q.v.). 

Peritonitis  without  perforation  adds  to  the  gravity,  but  is  not 
necessarily  fatal. 

Lobar  pneumonia,  hypostatic  congestion,  and  bronchitis  are  frequent 
occurrences.  There  are  few  cases  that  do  not  have  slight  bronchial 
cough  from  the  onset.  Albuminuria  and  acute  nephritis  may  occur, 
as  may  also  thrombosis  of  the  femoral  vein,  usually  the  left.  Bed- 
sores are  frequent,  resulting  from  the  impaired  nutrition,  emaciation, 
pressure  over  bony  prominences,  and  uncleanliness. 

Ulceration  of  the  tongue  and  mucous  membrane  of  the  cheek  is 
sometimes  observed. 

Sequelae. — Paralysis — either  monoplegia  or  paraplegia — may  take 
place,  due  to  an  acute  neuritis.  Post-febrile  insanity  occurs  more 
frequently  after  typhoid  than  any  other  febrile  condition  except 
influenza.  Acute  nephritis  associated  with  edema,  alopecia,  com- 
plete or  partial,  transverse  markings  of  the  nails,  and  tuberculosis  may 
develop. 

Varieties. — Abortive  typhoid  is  that  variety  in  which  convales- 
cence is  established  within  ten  days  or  two  weeks  after  an  abrupt 
onset  with  marked  symptoms.  Mild  typhoid  is  characterized  by 
moderate  fever,  slight  diarrhea,  and  few  if  any  nervous  symptoms. 
Ambulant,  or  walking  typhoid,  is  a  mild  type  in  which  the  symptoms 
are  so  slight  as  often  to  be  disregarded  by  the  patient.  Cases 
of  this  character  often  terminate  fatally  from  the  very  sudden  occur- 
rence of  perforation  and  other  serious  complications.  Typhoid  in 
children  is  nearly  always  marked  by  the  predominance  of  the  nervous 
symptoms. 

A  condition  known  as  the  Typhoid  state  frequently  occurs  in  the 


20 


TYPHOID   FEVER 


latter  half  of  the  second  week.  It  is  characterized  by  delirium,  car- 
phologia,  coma  or  drowsiness,  a  tendency  to  slip  to  the  foot  of  the 
bed,  muscular  weakness,  subsultus  tendinum,  soft  and  rapid  pulse,  dry 
and  furred  tongue,  and  sordes  in  the  teeth  and  lips.  This  condition 
is  not  peculiar  to  typhoid  fever,  but  is  found  in  all  malignant  types 
of  fever  such  as  small-pox,  pneumonia,  and  typhus. 

Relapses  are  not  uncommon.  The  symptoms  are  nearly  all 
repeated  but  are  less  intense  than  those  of  the  original  attack. 
A  sudden  elevation  of  temperature  during  convalescence  independ- 
ent of  other  symptoms  is  termed  recrudescence  and  is  due  to  excite- 
ment or  gastrointestinal  disturbances. 

Diagnosis. — The  Widal  Reaction.  Widal  and  others  have  shown 
that  serum  from  the  blood  of  one  ill  with  typhoid  fever,  if  mixed 
with  a  recent  culture,  will  cause  the  typhoid 
bacilli  to  lose  their  motility  and  gather  in  groups, 
the  whole  called  "clumping."  "Three  drops  of 
blood  are  taken  from  the  well-washed  aseptic 
finger-tip  or  lobe  of  the  ear,  and  each  lies  by 
itself  on  a  sterile  slide,  passed  through  a  flame 
and  cooled  just  before  use;  this  slide  may 
giuww  Sf  (Widaii  be  wrapped  in  cotton  and  transported  for 
Upper   segment,  shows  examination  at  the  laboratory.     Here  one  drop 

the  freely  moving  germs. 

The  lower  the  typical  is  mixed  with  a  large  drop  of  sterile  water  to 
Greene's  Medical  redissolve  it.  A  drop  from  the  summit  of  this 
lagnosis.)  .^  then  mixed  with  six  drops   of  fresh  broth 

culture  of  the  bacillus  (not  over  twenty-four  hours  old)  on  a  sterile 
slide.  From  this  a  small  drop  of  mingled  culture  and  blood  is 
placed  in  the  middle  of  a  sterile  cover-glass,  and  this  is  inverted 
over  a  sterile  hollow-ground  slide  and  examined.  .  .  A  positive 
reaction  is  obtained  when  all  the  bacilli  present  gather  in  one  or 
two  masses  or  clumps  and  cease  their  rapid  movement  inside  of 
twenty  minutes." 

The  reaction  seldom  appears  before  the  seventh  or  eighth  day  and 
may  persist  after  recovery.   , 

The  Widal  test,  if  positive,  is  practically  pathognomonic  and  should 
be  made  a  regular  method  of  examination  in  all  but  the  most  typical 
conditions.     A  negative  test  is  of  no  value. 

Other  tests,  such  as  the-Ehrlich's  diazo-reaction  and  Russo's  test, 
have  no  diagnostic  value  as  they  are  observed  in  many  other  condi- 
tions.    These  tests  are  described  on  pages  322  and  323. 


TYPHOID   FEVER  21 

The  characteristic  symptoms  that  serve  to  distinguish  typhoid 
fever  from  other  diseases  in  which  depression  is  a  marked  feature  are 
the  Widal  reaction,  the  temperature,  the  eruption,  a  low  leukocyte 
count,  the  diarrhea,  and  the  enlarged  spleen. 

Typhus  fever  is  uncommon  and  the  differential  diagnosis  of  these 
two  diseases  has  now  only  an  academic  (or  examinational)  interest; 
see  under  Typhus  Fever,  page  30. 

Enteritis  has  intestinal  derangement  and  an  irregular  fever. 

Peritonitis  is  attended  with  abdominal  symptoms  only,  with  con- 
stipation and  rapid  early  prostration,  and  collapse. 

Acute  miliary  tuberculosis  may  be  mistaken  for  typhoid  fever. 
The  temperature  record  is  more  irregular;  there  is  no  eruption;  the 
pulmonary  symptoms  are  more  pronounced;  the  abdominal  symp- 
toms are  less  marked;  tubercles  may  be  detected  by  the  ophthalmo- 
scope; and  the  Widal  reaction  is  not  obtained  in  tuberculosis. 

Meningitis  resembles  typhoid  fever  somewhat  but  may  be  dis- 
tinguished from  it  by  its  sudden  onset,  marked  cerebral  manifesta- 
tions from  the  very  beginning,  leukocytosis,  the  absence  of  the  charac- 
teristic symptoms  and  reactions  of  typhoid  already  given,  and  the 
presence  of  meningococci  in  the  cerebrospinal  fluid  obtained  by 
lumbar  puncture,  and  Kernig's  sign. 

In  ulcerative  endocarditis  the  abdominal  tenderness,  the  eruption 
and  headache  are  not  common,  the  Widal  test  will  be  negative,  and 
the  fever  is  not  so  persistent  and  characteristic. 

Malaria  may  simulate  typhoid  fever  but  the  blood  examination 
will  serve  to  clear  up  the  diagnosis.  Both  diseases  may  be  present 
coincidently  in  the  same  patient;  but  the  mongrel  affection  typho- 
malaria,  so-called,  does  not  exist  as  such. 

Concealed  suppuration  will  be  distinguished  by  the  fever  chart 
and  the   leukocytosis. 

Prognosis. — A  positive  prognosis  cannot  be  made.  Favorable 
indications  are  constipation  or  slight  diarrhea,  low  temperature, 
and  moderate  delirium.  Unfavorable  symptoms  are  obstinate  and 
severe  diarrhea,  early  high  temperature,  cardiac  exhaustion,  marked 
nervous  symptoms  with  coma  vigil  or  stupor,  albuminuria,  and  re- 
peated intestinal  hemorrhages. 

The  prognosis  is  always  more  favorable  in  winter  than  in  summer. 

When  death  occurs  it  is  usually  during  or  about  the  third  week, 
the  result  of  exhaustion,  cardiac  failure,  or  some  complication. 
Children  under  puberty  usually  recover.     More  women  than  men 


22  TYPHOID  FEVER 

die,  although  less  women  have  the  disease.  Pregnant  women  and 
fleshy  people  usually  succumb. 

The  mortality  in  typhoid  fever  in  private  practice  is  about  one 
death  in  twenty;  in  hospital  practice  it  varies  from  one  death  in 
five  to  ten  cases,  although  the  cold-bath  treatment  has  greatly  re- 
duced the  hospital  mortality. 

Protective  inoculation  against  typhoid  has  been  tried  with  gratify- 
ing results,  a  vaccine  prepared  by  Sir  A.  E.  Wright  being  used  for  the 
purpose.  It  is  said  to  bestow  immunity  for  two  or  three  years  and 
to  be  practically  harmless. 

Tjrphoid  vaccine  is  administered  hypodermically  under  aseptic 
conditions.  The  site  of  the  inoculation  should  be  steriHzed  by  the 
application  of  tincture  of  iodine  and  the  vaccine  injected  with  a  sterile 
syringe.  The  inoculation  is  usually  made  in  three  doses,  the  first 
consisting  of  500  million  killed  bacteria.  The  second  dose  of  1000 
million  bacteria  is  given  after  an  interval  of  from  a  week  to  ten  days 
and  the  third  dose  of  1000  million  after  a  similar  interval. 

Typhoid  Carriers. — The  typhoid  bacilli  can  live  in  the  body 
(especially  in  the  gall-bladder)  long  after  the  patient  has  recovered, 
and  this  fact  explains  some  outbreaks  of  typhoid  hitherto  of  obscure 
origin.  Both  feces  and  urine  may  be  extremely  active  in  the  dis- 
semination of  the  disease;  and,  with  regard  to  the  urine  alone,  Mc- 
Crae  says:  "The  number  which  may  be  present  is  enormous,  and 
billions  of  bacilli  may  be  excreted  each  day;  if  we  consider  the  length 
of  time  during  which  typhoid  bacilli  may  remain  in  the  urine,  it  is 
no  exaggeration  to  say  that  a  man  may  scatter  infection  around  the 
world." 

Prophylaxis. — Typhoid  fever  is  preventable.  When  the  municipal 
authorities  do  not  consider  it  their  duty  to  supply  pure  water,  each 
household  should  boil  all  water  that  is  to  be  used  for  drinking  or  for 
washing  dishes,  etc.;  milk  should  be  boiled  also;  and  no  ice  should 
be  put  in  water  or  other  drink  or  food;  fiies  should  be  kept  out  of  the 
house  as  far  as  possible,  by  means  of  screens  or  otherwise;  all  dis- 
charges from  the  sick  person  must  be  disinfected;  all  utensils,  dishes, 
etc.,  used  by  the  patient  must  be  thoroughly  cleansed  and  boiled 
every  day;  soiled  linen  must  be  soaked  in  a  disinfectant  solution 
before  being  washed;  after  each  attendance  on  a  patient  physicians, 
nurses,  and  others  should  wash  their  hands  in  a  disinfectant;  thorough 
sterilization  of  all  bedding,  etc.,  must  be  performed  after  the 
disease  is  over. 


TYPHOID   FEVER  23 

In  addition,  the  public  should  be  educated  to  keep  away  from  all 
known  or  suspected  cases  of  typhoid,  to  avoid  bathing  in  polluted 
waters,  to  abstain  from  oysters  and  other  shell-fish  of  unknown  origin 
and  to  be  vaccinated  against  typhoid  when  any  special  exposure  is 
anticipated  (see  page  22). 

Treatment. — The  patient  should  be  placed  immediately  in  bed 
in  a  quiet,  well-ventilated  room  having  an  average  temperature  of 
6s°F.  Intelligent  nursing  is  indispensable.  The  manner  in  which 
the  disease  is  disseminated  necessitates  the  most  scrupulous  cleanli- 
ness of  the  patient,  the  bedding,  and  the  various  sick-room  requisites. 
The  bed-pan  should  be  employed  through  the  entire  course  of  the 
disease  and  the  excreta  may  be  rendered  innocuous  by  being  passed 
into  twice  their  (expected)  volume  of  chlorinated  lime  (i  per  cent,  so- 
lution) or  carbolic  acid  (5  per  cent,  solution)  and  allowing  the  mix- 
ture to  remain  in  a  closed  vessel  for  two  or  three  hours  before  being 
finally  disposed  of  through  the  sewer  or  by  being  buried.  Bed-linen, 
or  other  clothing,  that  may  have  become  contaminated  should  be 
disinfected  by  boiling. 

The  diet  should  be  liquid  and  should  be  given  in  small  quantities 
at  intervals  of  two  or  three  hours.  Diluted  milk,  broths,  soups, 
white  of  egg,  coffee,  tea,  buttermilk,  junket,  albumin  water,  and 
similar  foods  are  permissible,  but  milk  is  undoubtedly  the  best. 
The  appearance  of  curds  in  the  stools  indicates  that  the  quantity  of 
milk  given  is  in  excess. 

Usually  it  is  best  to  dilute  the  milk  with  water,  adding  a  small 
quantity  of  lime  water,  or  to  administer  it  mixed  with  some  carbon- 
ated water.  The  average  quantity  of  milk  to  be  given  at  one  time 
is  about  5  ounces.  To  allay  the  thirst,  cool  water  may  be  given  in 
small  quantities  at  a  time;  the  patient  requires  much  water.  Wash- 
ing the  tongue,  lips,  and  mouth  are  also  effective  in  this  respect. 
Prostration  is  avoided  to  a  great  extent  by  regular  feeding  every 
two  hours,  but  should  the  heart  begin  to  weaken  and  the  pulse  be- 
come soft,  whiskey  or  brandy,  in  half-ounce  doses  every  three  hours, 
should  be  administered,  preferably  with  milk  so  as  to  aid  in  the  digest- 
ive process.  The  periods  of  nourishment  and  stimulation  should 
be  the  same  if  possible  and  should  not  be  interfered  with  by  sleep. 
Just  now  there  is  a  tendency  to  grant  a  more  liberal  diet  than  was 
formerly  advised,  but  the  practitioner  should  remember  that  it  is 
easy  to  overfeed  a  typhoid  patient,  and  that  in  severe  cases  the  digest- 
ive functions  are  in  abeyance.     The  inclusion  of  solid  foods  in  the 


24  TYPHOID   FEVER 

dietary  should  not  be  considered  until  the  temperature  has  remained 
normal  for  at  least  one  week. 

Coleman's  high  calorie  diet  has  proved  highly  successful;  it  has 
shortened  the  convalescence,  ehminatedsomeof  the  distressing  symp- 
toms, and  lessened  the  mortality.  Patients  thus  treated  were  found 
to  have  a  cleaner,  moister  tongue,  more  corrifortable  mouth,  less 
offensive  breath,  less  emaciation,  less  nervous  exhaustion,  a  cleaner, 
healthier  skin,  greater  comfort,  less  diarrhea.  Probably  a  lessened 
mortality;  fewer  complications ;  maintenance  of  weight  and  nutrition; 
the  amelioration  of  hunger;  and  the  lessened  tedium  of  convalescence, 
are  marked  features  of  high  calorie  feeding  in  typhoid  fever.  Each 
case  is  treated  according  to  its.  own  individual  needs;  and  the  treat- 
ment demands  unremitting  attention  to  details.  Each  patient  is 
supposed  to  receive  food  of  the  value  of  3000  calories;  theoretically, 
5000  calories  are  indicated,  but  3000  are  accepted  as  a  compromise. 

The  reduction  of  temperature  is  perhaps  the  most  important  indica- 
tion in  the  management  of  this  disease.  This  is  best  accomplished 
by  hydrotherapy.  Cold  sponging  with  water,  or  alcohol  and  water, 
is  often  of  value  in  mild  cases  and  to  be  effective  the  surface  should 
be  left  very  wet,  being  careful  not  to  expose  too  great  a  portion  of  the 
body-surface  at  a  time.  The  cold  pack  is  of  value  in  cases  attended 
by  rather  high  temperatures  (104°  to  io5°F.)  and  is  employed  when 
for  any  reason  the  tub -bath  is  impracticable.  The  bed  should  be 
protected  by  a  rubber  cloth,  and  the  patient,  with  his  clothing  re- 
moved, should  be  wrapped  in  a  sheet  wrung  out  of  cold  water.  The 
surface  should  be  rubbed  briskly  through  the  sheet,  and  from  time 
to  time  cold  water  is  freely  sprinkled  over  the  sheet.  Friction  must 
be  continued  during  the  pack,  and  ice  cloths  or  cap  placed  on  the 
head.  The  duration  of  the  cold  pack  is  determined  by  the  tempera- 
ture and  the  reaction  powers  of  the  patient.  Collapse  may  be 
avoided  by  the  administration  of  whiskey  or  brandy,  or  the  hypo- 
dermic injection  of  strychnine  before  or  after  the  pack  according  to 
the  patient's  condition. 

The  cold  bath,  after  the  method  of  Brand,  or  '' tubbing, "  has  proven 
most  prompt  and  decided  for  reducing  temperature.  It  consists  in 
the  systematic  employment  of  general  cold  baths,  with  frictions, 
whenever  the  temperature  reaches  102. 2 °F.  As  often  as  the  tem- 
perature, taken  every  three  hours  in  the  mouth  or  rectum,  is  over 
io2.2°F.  the  patient  receives  a  bath  lasting  fifteen  or  twenty  minutes. 
He  wears  a  thin  muslin  garment  Or  is  wrapped  in  a  sheet;  he  is  given 


TYPHOID    FEVER  25 

a  stimulant  and  carefully  lifted  into  the  bath  of  65°  or  7o°F.,  some 
cold  water  being  poured  over  his  head  and  shoulders  to  lessen  the 
shock;  the  head  rests  on  an  air  pillow,  the  body  submerged  to  the 
neck.  During  the  whole  period  of  the  bath  the  patient  must  he  briskly 
rubbed.  The  friction  and  affusion  are  of  value  in  preventing  chill 
arid  cyanosis.  After  the  bath  the  wet  linen  is  quickly  removed  and 
the  patient  placed  in  bed,  wrapped  in  a  dry  sheet,  and  covered  with  a 
blanket.  A  stimulant  is  again  given  after  the  bath,  and  if  there  is 
any  tendency  to  cyanosis  or  heart  failure,  a  hypodermic  injection  of 
strychnine.  The  temperature  is  taken  after  the  patient  is  placed 
in  bed  and  again  in  half  to  three-quarters  of  an  hour,  and  if  not  then 
io2°F.,  is  not  again  taken  for  three  hours.  Not  more  than  eight 
such  baths  should  be  given  in  twenty-four  hours.  The  good  effects 
of  the  bath  are  seen  in  a  reduction  of  temperature,  clearer  intellect, 
and  lessening  stupor  and  muscular  twitching.  Sleep  usually  follows 
a  bath,  with  a  general  stimulating  effect  upon  the  heart  and  the 
nervous  system. 

Contraindications  to  the  Brand  bath  are  hemorrhage,  perforation, 
or  peritonitis;  extreme  age  and  weakness;  pleurisy  or  pneumonia; 
when  the  bath  causes  intense  cyanosis  or  much  dyspnea  or  coughing. 
The  various  antipyretic  drugs,  such  as  antipyrine,  acetanilide, 
phenacetin,  etc.,  while  successful  in  reducing  temperature,  should 
never  be  substituted  for  the  bath  treatment  as  they  add  to  the  already 
intense  exhaustion.  Quinine  sulphate  in  small  doses  is  of  value  in 
that  it  tends  to  lower  the  fever  and  at  the  same  time  is  tonic  and  more 
or  less  stimulating.  The  quinine  should  be  dissolved  in  citric  acid 
and  given  as  an  effervescent  draught  by  the  addition  of  an  alkaline 
mixture,  when  doses  of  2  or  3  gr,  will  be  found  to  have  a  decided  an- 
tipyretic influence. 

Diarrhea  should  not  be  checked  unless  it  exceeds  three  or  four 
stools  in  twenty-four  hours,  when  the  following  may  be  used: 
I^.     Bismuth,  subnitrat gr.  xx  1.3       gm. 

Phenol gr.  j-  0.06    gm. 

Tinct.  opii  deodorat lUviij  0.5      c.c, 

Mucil.  acaciae 5j  4-0      c.c. 

Aquae f  5iij  12.0      c.c. 

M.  S. — Every  three  or  four  hours. 
Or— 

I^.     Cupri  sulphat gr.  ^^  o.oii  gm. 

Extracti  opii gr.  Ji  0.016  gm. 

M.  S. — In  pill,  every  four  hours. 


26  TYPHOID   FEVER 

At  the  onset  of  a  suspected  case  of  typhoid  fever,  when  there  are 
present  coated  tongue,  fetid  breath,  anorexia,  chilliness  followed  by 
feverishness  or  fever,  nervousness,  costiveness  or  frequent  tenesmic 
stools,  and  general  soreness  associated  with  mental  unrest  and  head- 
ache, excellent  results  follow  the  use  of  the  following  combination: 

I^.     Hydrargyri  chlor.  mit gr.  viij  0.52  gm. 

Sodii  bicarbonatis gr.  xv  i.o  gm. 

Pulv.  ipecacuanhae gr.  ij  "0-i3  gm. 

Salol gr.  XV  i.o  gm. 

M.  Ft.  chart.  No.  xv. 

S. — One  powder  every  three  hours  until  decided  bowel  action. 
Or— 

I^.     Acid,  sulph.  aromat lUxv  i ,  o  c.c. 

Tinct.  opii  deodorat TTtx  o ,  6  c.c. 

M.  S. — In  water,  every  three  hours. 

Constipation  in  the  course  of  the  disease  is  best  relieved  by  enemas, 
or  by  calomel  in  divided  doses. 

Tympanites  may  be  relieved  by  the  application  of  cold  compresses, 
an  ice-bag,  or  a  turpentine  stupe  to  the  abdomen.  In  extreme  cases 
the  introduction  of  a  soft-rubber  catheter  high  up  in  the  rectum  will 
afford  relief.  If  the  tympany  is  associated  with  constipation,  ten 
minims  of  oil  of  turpentine  and  fifteen  minims  of  castor  oil  in  emulsion, 
administered  every  three  or  four  hours,  will  prove  very  beneficial. 
The  quantity  of  food  should  be  lessened  in  many  cases  as  the  disten- 
tion is  often  due  to  fermentation  of  undigested  food. 

Headache  when  excessive  may  be  reheved  by  the  application  of 
cold  to  the  head  and  mustard  to  the  neck  and  by  foot-baths.  Mor- 
phine and  atropine  hypodermically  may  be  required.  Leeches  are 
rarely  necessary. 

Delirium  is  to  a  large  extent  prevented  by  combating  the  general 
exhaustion.  The  use  of  stimulants  and  hydrotherapy  control  it  in 
most  cases,  but  camphor,  musk,  or  morphine  may  be  required. 

Insomnia  is  sometimes  a  very  troublesome  symptom  and  necessi- 
tates the  employment  of  trional,  sodium  bromide,  or  even  morphine 
(or  codeine). 

Cystitis  may  occur  in  typhoid  fever  and  should  be  carefully  guarded 
against  by  daily  examination  over  the  bladder,  and  irrigation  with 
sterile  boric  acid  solution  on  the  first  signs  of  vesical  irritation. 

Intestinal  hemorrhage  indicates  absolute  rest  and  suspension  of 
cold  bathing.     The  foot  of  the  bed  should  be  slightly  elevated  and  an 


TYPHOID   FEVER  27 

ice-bag  placed  over  the  right  iliac  region.  Morphine,  gr.  3<4,  should 
be  given  hypodermically  at  once.  Fluidextract  of  ergot,  f  3  j  (4  c.c), 
Monsel's  solution,  Tllv  to  x!  (0.3  to  0.6  gm.),  or  oil  of  turpentine,  T([x 
(0.6  c.c),  should  be  administered  every  two  hours.  The  quantity  of 
food  should  be  reduced  to  the  minimum  and  in  some  cases  feeding 
should  be  suspended  for  twelve  hours  or  more. 

Perforation  and  peritonitis  are  the  most  serious  complications, 
and  demand  the  immediate  services  of  a  competent  surgeon  as  soon 
as  detected.  The  early  operations  are  attended  with  the  best  results, 
and  delay  in  operating  is  far  more  dangerous  than  the  operation  it- 
self. Keen  says  that  if  the  operation  is  not  done  within  about  twenty- 
four  hours  after  the  perforation,  there  is  probably  no  hope  of  recovery. 

Bed-sores  are  prevented  by  scrupulous  cleanliness  as  regards  the 
patient  and  the  bed,  and  by  the  avoidance  of  uneven  pressure  such 
as  is  caused  by  crumbs,  wrinkled  sheets,  etc.  Bathing  with  alcohol, 
frequently  changing  of  the  patient's  position,  and  the  use  of  an  air 
cushion  are  of  value. 

Lobar  pneumonia  and  bronchial  catarrh  call  for  dry  cups  and  the 
use  of  the  following  mixture: 

I^.     Ammonii  chlorid 5ij  8 .  o      gm. 

Strychninas  sulphat g^-  li  0.02    gm. 

Spt.  chloroformi f  5  j  4-0      c.c. 

Aq.  lauro-cerasi.    . .  .q.  s.  ad  f  §iv  120.0      c.c. 

M.  vS. — Dessertspoonful  every  two,  three,  or  four  hours,  diluted. 

In  all  cases  the  patient  should  be  supported  by  the  administration 
of  strychnine  sulphate,  gr,  3^2  (0.002  gm.),  every  four  hours,  and 
if  the  debility  becomes  extreme  aromatic  spirit  of  ammonia,  f3j 
(4  c.c),  or  spirit  of  chloroform  TTlij  (0.12  to  0.3  c.c),  may  be  given 
every  two  hours  in  addition.  If  the  tongue  becomes  dry,  brown  and 
fissured,  the  following  formula  will  be  found  useful: 

I^.     Olei  terebinthinae f^ss  15  c.c. 

Mucil.  acaciae q.s.  q.s. 

01.  sassafras ..    TTtxv  i  c.c. 

Aq.  chloroformi.  .  .  .q.  s.  ad  f  3iv  120  c.c. 

M.  S. — One  teaspoonful  every  two  or  three  hours,  diluted. 

Convalescence  should  be  carefully  guarded.  The  return  of  solid 
food  should  be  extremely  slow.  Exercise  should  be  of  the  most  mild 
character   for   several  weeks.     Quinine  and  belladonna,  internally, 


28  PARATYPHOID   FEVER 

will  serve  to  control  cardiac  palpitation  and  excessive  sweating  during 
this  period.  Any  tendency  toward  diarrhea  may  be  checked  by 
nitrate  of  silver,  nux  vomica,  or  strychnine.  The  malt  liquors  are 
of  value  in  prolonged  convalescence.  The  elixir  of  iron,  quinine,  and 
strychnine  (N.F.)  is  uSeful. 

Quarantine. — A  child  who  has  been  exposed  to  infection  should 
not  be  allowed  to  return  to  school  till  at  least  twenty-one  days  after 
the  date  of  such  (last)  exposure. 

PARATYPHOID    FEVER 

This  is  an  infectious  fever  produced  by  a  special  bacillus,  inter- 
mediate between  the  typhoid  and  colon  form,  called  the  paratyphoid 
bacillus,  and  possessing  clinical  features  similar  to  those  of  typhoid, 
but  of  milder  type.  Diarrhea  and  termination  of  fever  by  crisis 
are  more  common  than  in  typhoid.  There  are  no  characteristic 
lesions.  The  spleen  is  enlarged;  sometimes  ulcers  may  be  found  in 
the  intestines,  but  Peyer's  patches  are  not  involved.  Purulent  ar- 
thritis and  myositis  may  occur  as  complications  in  this  disease,  but  are 
very  infrequent  in  typhoid.  The  blood  serum  in  this  disease  gives 
an  agglutination  reaction  with  fresh  cultures  of  the  paratyphoid 
bar'i  '\<\  but  not  with  typhoid  cultures.  The  diazo-reaction  is  gener- 
al itive.  The  outlook  is  more  favorable  than  in  typhoid  fever, 
anc  treatment  is  the  same. 

TYPHUS   FEVER 

Synon3rms. — Ship  fever;  jail  fever;  petechial  typhus;  spotted  or 
putrid  fever;  tabardillo;  the  Germans  call  it  exanthematic  typhus  to 
distinguish  it  from  abdominal  typhus  (typhoid). 

Definition. — An  acute,  infectious,  and  epidemic  fever;  highly 
contagious,  and  characterized  by  sudden  invasion,  profound  depres- 
sion of  the  vital  powers,  sickening  odor,  and  a  peculiar  maculated 
and  petechial  eruption,  favorable  cases  terminating  by  crisis  about 
the  fourteenth  day.     There  are  no  characteristic  lesions. 

Cause. — It  is  due  to  a  special  organism,  the  Bacillus  typhi  exanthe- 
matici,  recently  (191 5)  isolated  by  Plotz.  It  is  probably  carried  by 
bed-bugs  and  body  lice.  The  disease  is  rarely  seen  in  the  United 
States. 

Pathology. — There  are  no  constant  lesions  peculiar  to  this  affection. 
The  blood  is  dark  and  thin,  with  a  decrease  in  fibrin;  and  the  tissues 


TYPHUS   FEVER 


29 


are   affected   with   parenchymatous   degenerations.     The   petechial 
rash  remains  after  death. 

Symptoms.— After  an  incubation  period  varying  from  a  few  hours 
to  two  weeks  (generally  about  twelve  days)  the  disease  makes  its 
appearance  suddenly  with  a  chill,  followed  by-pains  in  the  head,  back, 
and  limbs,  and  fever,  the  temperature  reaching  105°  or  io6°F. 
within  a  few  days.  A  severe  angina  is  frequently  the  first  symptom. 
The  high  temperature  is  maintained  for  about  two  weeks  when  it  falls 


Fig.  3.  — Clinical  Chart  of  Typhus  Fever  Ending  in  Recovery.      {From  Wilcox's  Fever 

Nursing.) 


by:  crisis.  The  pulse  is  at  first  frequent  and  bounding,  but  soon 
becomes  small,  weak  and  rapid.  The  patient  protrudes  his  tongue 
with  difficulty,  and  often  is  unable  to  project  it  beyond  his  teeth. 
Prostration  is  extreme  and  is  manifested  by  muscular  feebleness, 
vertigo,  tremor,  and  subsultus.  On  the  third  to  the  fifth  day  a  coarse, 
red,  diffused,  measly  eruption  makes  its  appearance  which  rapidly 
becomes  petechial  or  hemorrhagic.  Associated  with  this  is  diffuse 
mottling  of  the  skin  which  involves  the  entire  body,  excepting  the 
face.  The  face  has  a  uniform  deep  dusky  flush  and  the  skin  appears 
glazed.  The  conjunctivse  are  injected  and  the  pupils  are  contracted. 
As  the  disease  progresses  there  is  cutaneous  hyperesthesia,  muscular 


30  CEREBROSPINAL   FEVER 

soreness,  and  tenderness  over  the  tibia.  Headache  is  severe  and 
often  followed  by  delirium.  Constipation  is  the  rule.  The  urine  is 
that  of  all  high  fevers. 

Complications. — Bronchopneumonia,  gangrene  of  the  lungs,  and 
swollen  parotid  glands  are  the  most  common;  hyperpyrexia,  early 
typhoid  state,  and  bed-sores  are  also  to  be  expected. 

Diagnosis. — It  may  be  distinguished  from  typhoid  fever  by  the 
sudden  onset,  the  rapid  rise  of  temperature,  the  fever  record,  the 
earUer  appearance  and  distribution  of  the  eruption,  and  the  absence 
of  abdominal  symptoms,  Widal  reaction,  and  diazo-reaction. 

Measles  begins  with  coryza  and  cough  and  has  an  entirely  different 
course  except  in  the  case  of  hemorrhagic  measles;  Kophk's  spots 
are  often  found. 

Cerebrospinal  fever  is  attended  by  more  intense  nervous  phenomena 
but  there  is  no  constant  eruption.  Prostration  is  not  so  great, 
vomiting  is  more  common,  and  the  fever  is  not  quite  so  high;  the 
character  of  the  prevailing  epidemic  will  often  help.  Lumbar  punc- 
ture and  Kernig's  sign  will  settle  the  diagnosis. 

Brill's  disease  is  a  mild  atypical  form  of  typhus. 

Prognosis. — The  duration  is  usually  about  two  weeks  and  the 
mortality  varies  from  5  to  35  per  cent.  High  temperature,  frequent 
pulse,  early  stupor,  and  great  anxiety  are  unfavorable  indications. 

Treatment. — Isolation  is  imperative.  Disinfection  of  clothing 
and  excreta  is  necessary.  Body  lice  and  bed-bugs  (the  carriers  of 
the  disease)  are  best  destroyed  by  steam.  The  patient  should  be 
treated  in  the  open  air  if  possible  and  the  various  symptoms  combated 
as  in  typhoid  fever.  Hydrotherapy  should  be  employed  to  reduce 
the  temperature;  apart  from  this  there  is  no  special  treatment, 
except  to  support  and  stimulate  the  patient. 

CEREBROSPINAL  FEVER 

Synonyms. — Epidemic  cerebrospinal  meningitis;  epidemic  cere- 
brospinal fever;  spotted  fever;  petechial  fever. 

Definition. — An  acute  severe  infectious  fever,  characterized  by 
headache,  vomiting,  painful  contractions  of  the  muscles  of  the  back 
of  the  neck,  retraction  of  the  head,  hyperesthesia,  disorders  of  the 
special  senses,  delirium,  stupor,  coma,  and  frequently  an  eruption 
of  petechias  or  purpuric  spots.  Lesions  of  cerebral  and  spinal  mem- 
branes are  found  at  the  postmortem. 

Causes. — The  disease  is  due  to  the  Diplococcus  intracellularis  of 


CEREBROSPINAL  FEVER 


31 


Weichselbaum  and  also  to  mixed  infection.  The  organism  is  found 
in  the  fluid  obtained  by  lumbar  puncture.  The  pneumococcus  may 
also  produce  this  disease.  Among  the  predisposing  causes  may  be 
mentioned  bad  hygiene,  filth,  overcrowding,  foul  air,  poor  food,  im- 
pure water,  exposure,  winter  season,  and  youth.  Its  method  of 
transmission  is  by  the  nasal  passages.  It  is  epidemic  and  sporadic. 
Osier  gives  the  following  table  showing  the  organisms  causing  the 
various  forms  of  cerebrospinal  meningitis: 

Diplococcus  intracellularis. 


H 

"l-l 


1.  Of  cerebrospinal 

fever. 

2.  Pneumococcic. 


Pneumococcus. 


/  (a)   Sporadic. 

i{b)    Epidemic. 
Meninges     alone      involved 
or  in   a   general   pneumo- 
coccus-infection.  , 

Tuberculous •    •    .Bacillus  tuberculosis 

'  (a)   Secondary    to    pneumo-  | 
nia,  endocarditis,  etc.  | 

(6)    Secondary      to      disease  j-  Pneumococcus 
or   injury    of    cranium    or 
its  fossae.  , 

(a)   Following    local    disease 
of  cranium  or  a  local  in- 
fection elsewhere. 
(6)    Terminal     infection     in 
I      various  chronic  maladies. 
'  In  typhoid  fever,  influenza, 
diphtheria,  gonorrhea, 

anthrax,       actinomycosis, 
and  other  acute  diseases. 


2.  Pneumococcic. 


3.   Pyogenic. 


Miscellaneous  acute 
infections. 


Various  forms  of  sta- 
phylococci and  strep- 
tococci. 

Typhoid  bacillus,  influ- 
enza-bacillus, diph- 
theria-bacillus, g  o  n  o- 
coccus,  etc. 


Pathological  Anatomy. — In  nearly  all  cases  there  is  hyperemia 
of  the  membranes  (pia  and  arachnoid)  of  the  brain  and  spinal  cord 
followed  by  an  exudation  of  lympth  and  an  effu- 
sion of  serum  most  marked  at  the  base  of  the 
brain.  The  cranial  and  spinal  nerves  are  simi- 
larly affected  in  severe  cases .  The  lungs,  spleen, 
stomach,  liver,  kidneys,  bladder,  and  muscles 
are  in  various  stages  of  congestion  and  paren- 
chymatous degeneration.  In  some  cases  death 
results  from  profound  toxemia  before  structural 
changes  have  taken  place. 

Symptoms. — The  comtnojtfonnhegms  abruptly 
with  a  chill,  excruciating  headache,  persistent 
nausea,  vomiting,  vertigo,  and  weakness.  The 
muscles  of  the  back  of  the  neck  soon  become 
rigid  and  retracted.  The  muscles  of  the 
back  are  shortly  involved  in  a  similar 
in  opisthotonus,  or  arching  of  the  back.  Kernig's  sign 
(inability  to  straighten  the  leg  completely  when  the  thigh  is  flexed 
upon  the  abdomen,  the  patient  being  in  the  recumbent  posture) 


Fig.  4. — -Diplococcus 
intracellularis  meningi- 
tidis. (Weichselbaum.) 
In  actual  specimens  the 
germs  are  (like  the  gon- 
ococcus)  chiefly  within 
the  polynuclear  leuko- 
cytes. {Greene's  Medical 
Diagnosis.  ) 


manner,     resulting 


2>^ 


CEREBROSPINAL   EEVER 


is  nearly  always  obtained;  and  as  it  is  almost  never  found  in  other 
diseases,  or  in  health,  it  is  practically  pathognomonic  of  this  disease. 
There  is  great  restlessness  and  the  surface  of  the  body  becomes  hyper- 
esthetic.  Muscular  cramps  are  common  and  convulsions  and  delirium 
are  frequent.  Arthritis  is  not  uncommon.  Involvement  of  the 
special  nerves  induces  intolerance  to  light  and  sound,  blindness, 
deafness,  loss  of  senses  of  smell  and  taste,  tremor  of  the  eyeballs 
and  paralysis  of  ocular  muscles.     The  temperature  and  pulse  record 


Fig.  5. — Kermg's  sign. 
Proper  method,  i.e.,  pre- 
liminary flexion  of  thighs 
on  abdomen  followed  by 
attempted  extension  of  leg 
on  thigh  {Greene's  Medical 
Diagnosis.) 


Fig.  6. — Kernig's  sign. 
Improper  method  lacking 
the  essential  preliminary 
flexion  of  thighs  upon  ab- 
domen. {From  Greene's 
Medical  Diagnosis.  After 
Sahli- Wiener.) 


are  irregular.  Emaciation  is  usually  present.  A  petechial  or  pur- 
puric eruption  makes  its  appearance  from  the  first  to  the  fifth  day. 
Herpes  facialis,  erythema,  or  urticaria  may  also  be  present.  The 
tache  cerebrate  is  usually  obtained.  Leukocytosis  of  about  24,000  to 
40,000  per  cm.  is  always  present.  Recently,  two  new  signs  have 
been  observed :  MacEwen  's  sign,  in  which  a  change  in  the  percussion 
note  is  found  over  the  lateral  ventricles,  due  to  increased  intraven- 
tricular pressure;  and  Brudzinski's  sign,  in  which  the  patient  flexes 
and  everts  the  arms  and  legs  when  an  attempt  is  made  to  flex  the 
head  on  the  chest.  The  duration  of  this  form  is  from  a  few 
hours  to  several  weeks  but  usually  it  reaches  its  height  in  from  three 
to  eight  days,  passing  into  either  stupor  and  coma  or  into  a  protracted 
convalescence. 

The  fulminajit  or  malignant  form  is  characterized  by  sudden  onset, 
violent  chills,  depression,  and  in  a  few  hours  collapse  and  death. 

The  abortive  form  consists  of  one  or  more  pronounced  characteristic 
symptoms  during  the  course  of  an  epidemic,  and  terminates  in 
prompt  recovery. 


CEREBROSPINAL   FEVER  33 

The  chronic  form  is  that  in  which  the  duration  is  unusually  pro- 
longed, and  is  attended  by  headache,  gastric  irritability,  and  vague 
pains;  it  usually  terminates  in  death  from  exhaustion  or  in  incom- 
plete recovery. 

Complications  and  Sequelag. — The  common  complications  are 
pleurisy,  pneumonia,  endocarditis,  pericarditis,  typhoid  fever,  poly- 
arthritis, and  intestinal  catarrh.  As  sequels  may  be  mentioned 
persistent  headache,  blindness,  deafness,  mental  feebleness,  chronic 
hydrocephalus,  epilepsy,  and  various  palsies. 

Diagnosis. — This  is  made  from  the  symptoms,  particularly  Ker- 
nig^s  sign.  Lumbar  puncture,  in  the  third  or  fourth  lumbar  inter- 
space, will  often  show  the  cerebrospinal  fluid  turbid,  bloody,  or 
purulent,  and  microscopic  examination  will  demonstrate  the  micro- 
organism. 

Differential  Diagnosis. — Typhoid  fever  begins  slowly  and  has  a 
characteristic  temperature,  less  headache,  and  no  muscular  rigidity 
or  opisthotonus.  The  eruption,  diarrhea,  absence  of  palsies  and 
Kernig's  sign,  and  the  presence  of  Widal's  reaction  should  serve  to 
make  the  distinction. 

Typhus  fever  has  a  definite  course  and  eruption  and  is  not  attended 
by  muscular  rigidity,  retraction,  disorders  of  the  special  senses,  or 
palsies. 

Tuberculous  meningitis  differs  in  that  it  is  not  epidemic,  has  no 
eruption,  is  preceded  by  long  prodromes,  runs  a  tedious  course,  and  a 
primary  focus  of  tuberculosis  may  usually  be  detected  elsewhere  in 
the  body. 

A  careful  history  and  examination  will  serve  to  differentiate  it 
from  small-pox,  influenza,  and  acute  articular  rheumatism  which  it 
sometimes  resembles. 

Prognosis. — The  course  of  the  disease  is  variable  and  uncertain. 
The  mortality  varies  according  to  the  epidemic  from  20  to  75  per 
cent.     Severe  cerebral  symptoms  are  of  unfavorable  significance. 

Treatment. — The  treatment  is  symptomatic  and  supportive. 
The  patient  should  be  isolated  in  a  large  airy  room  which  is  quiet, 
well  ventilated,  and  moderately  dark;  he  should  be  placed  in  bed  and 
nourished  by  milk,  eggs,  meat-juice,  broths,  etc.,  at  regular  intervals. 
Nutritive  enemas  may  be  necessary.  Morphine  sulphate,  gr.  }i  to 
>^  (0.016  to  0.032  gm.),  should  be  given  hypodermically  every  two 
hours  or  extract  of  opium,  gr.  j  (0.065  gm-);  may  be  administered  by 
the  mouth  every  hour  until  the  stage  of  effusion  and  its  consequent 


34  ACUTE   POLIOMYELITIS 

pressure  symptoms  appear.  Quinine  sulphate  and  potassium  iodide 
are  then  indicated.  Da  Costa  alternates  potassium  bromide  with 
opium,  especially  in  children.  The  convulsions  may  be  relieved  by 
chloral,  gr.  xxx  (2  gm.),  given  as  the  occasion  requires  it.  The  coal- 
tar  products  are  dangerous  in  this  disease  and  should  be  used  only 
with  the  greatest  caution.  Whiskey  and  brandy  are  indicated  to 
combat  collapse  but  should  not  be  used  in  the  early  stage.  All  secre- 
tions and  discharges,  and  everything  that  has  been  in  contact  with 
the  patient  must  be  disinfected. 

Locally,  cold  compresses  and  ice-bags  should  be  applied  to  the 
head  and  spine  and  counterirritation,  cupping,  and  leeching  over 
the  spine  may  be  employed.  Repeated  lumbar  punctures  are 
sometimes  of  value.  Injection  into  the  spinal  canal  of  lysol  (i  per 
cent,  solution)  and  diphtheria  antitoxin  have  been  employed  with 
some  degree  of  success.  Goldscheider  advocates  active  movements 
of  the  patient  while  submerged  in  a  bath  at  ordinary  temperatures. 
The  nasal  passages  should  be  cleansed  with  an  antiseptic  wash,  and 
the  nasal  discharges  burnt. 

Serum  treatment  has  proved  effective.  "Flexner  recommends 
doses  of  30  c.c.  of  his  serum  to  be  injected  directly  into  the  spinal 
meninges  after  the  withdrawal  of  50  c.c.  of  cerebrospinal  fluid;  of 
400  cases  thus  treated,  295  recovered"  (Osier). 

ACUTE    POLIOMYELITIS 

Synon3mis.— Infantile  paralysis;  epidemic  poliomyelitis;  acute 
anterior  poliomyelitis;  essential  paralysis  of  children;  atrophic 
paralysis  of  children. 

Definition. — An  acute  infectious  disease  characterized  by  a  rapidly 
developed  inflammation  of  the  anterior  horns  of  the  gray  matter  of 
the  cord,  occurring  suddenly  in  children,  occasionally  in  adults — 
acute  spinal  paralysis  of  adults— characterized  by  mild  fever,  mus- 
cular tremors  and  twitchings,  and  paralysis  of  groups  of  muscles, 
followed  by  more  or  less  atrophy. 

Causes. — The  disease  is  due  to  a  filterable  virus.  It  is  essentially 
a  disease  of  early  life,  from  the  second  month  to  the  third  or  fourth 
year,  but  it  may  rarely  be  observed  in  adults.  The  affection  is  more 
common  during  the  summer  months,  and  males  are  most  often  at- 
tacked. It  occasionally  appears  in  epidemic  form.  Exposure  to  cold 
and  damp,  dentition,  injuries,  and  the  infectious  fevers  may  act  as 


ACUTE   POLIOMYELITIS  35 

predisposing  causes.  The  nasopharynx  is  supposed  to  be  the  portal 
of  entry  as  well  as  the  place  of  exit;  and  the  disease  is  conveyed  by 
the  secretions  of  the  nose  and  bronchi  as  well  as  by  food,  dust  and  flies. 
Coughing,  sneezing  and  kissing  are  possible  means  of  dissemination; 
and  the  existence  of  ^'carriers"  must  be  remembered. 

Pathological  Anatomy. — The  early  changes  are :  Medullary  hyper- 
emia, vascular  exudation,  and  inflammatory  softening,  although  the 
naked  eye  may  not  recognize  any  changes.  Microscopic  examination 
reveals  inflammatory  softening  of  the  anterior  horns  of  the  gray  matter. 
Among  other  constant  lesions  are  atrophic  degeneration  of  -the 
multipolar  gangUon-cells  and  of  the  anterior  nerve-roots.  The 
changes  noted  as  occurring  in  the  cord  are  usually  limited  to  the  dorso- 
lumbar  and  cervical  enlargements.  The  virus  has  been  found  in 
the  central  nervous  system  and  in  the  cerebrospinal  fluid.  The 
tonsils  and  lymph  glands  are  enlarged. 

As  a  direct  result  of  the  changes  in  the  trophic  centers  and  the 
nerve  degeneration  of  the  muscular  fibers  supplied,  there  ensue 
changes  in  the  bones  and  joints,  leading  to  great  deformities. 

Symptoms. — The  onset  of  the  affection  varies;  it  may  be  acute, 
subacute,  or  chronic;  it  is  usually  sudden,  with  an  attack  of  mild 
fever  of  a  remittent  type,  of  a  few  days'  duration,  on  recovery 
from  which  it  is  noticed  that  the  child  is  paralyzed.  There  is  often 
pain  or  soreness  at  the  beginning  of  the  disease.  Rarely,  the  paralysis 
may  be  preceded  by  convulsions. 

The  paralysis  may  affect  both  arms  and  both  legs,  the  legs  alone, 
or  only  one  of  the  four  extremities;  it  may,  very  rarely,  be  a  hemi- 
plegia. As  a  rule,  however,  the  leg  suffers  more  frequently  than  the 
arm;  in  paralysis  of  the  leg  the  muscles  below  the  knee  suffer  more 
severely  than  those  above.  The  bladder  and  rectum  are  not  affected, 
or,  if  so,  only  temporarily,  and  anesthesia  or  numbness  cannot  be 
detected.  The  temperature  of  the  paralyzed  limb  is  low  and  the 
part  is  cyanosed  in  appearance.  After  a  few  days  there  is  a  slight 
improvement  in  the  paralyzed  parts,  although  the  muscles  show  a 
rapid  wasting,  which  is  progressive  until  all  muscular  tissue  is  gone. 
The  reflex  movements  are  impaired  or  abolished. 

The  electro-contractility  by  the  faradic  current  is  abolished  in 
the  paralyzed  parts. 

With  the  galvanic  or  constant  current  the  "reactions  of  degen- 
eration" are  developed.  To  fully  understand  the  meaning  of  this 
term  a  knowledge  of  the  normal  electrical  reactions  is  necessary. 


36  ACUTE   POLIOMYELITIS 

The  normal  formulas  for  the  production  of  muscular  contrac- 
tion in  the  physiological  state  are  as  follows,  the  strength  of  the  cur- 
rent being  barely  capable  of  causing  fair  contractions: 

1.  The  most  effective  contractions  are  produced  by  the  kathode 
(negative)  pole  on  closing  the  circuit  (K.C.)- 

2.  The  second  most  effective  are  produced  by  the  anode  (positive) 
pole  on  closing  the  circuit  (A.C.)- 

3.  The  next  most  effective  is  by  the  anode  pole  on  opening  the 
circuit  (A.O.). 

4.  Kathode  pole  contractions  on  opening  circuit  are  rarely  seen 
in  the  physiological  state  (K.O.)- 

The  ''reactions  of  degeneration"  are  shown  by  any  reversal  of  the 
regular  formulas;  as  when  the  anodal  closure  (A.C.)  shows  stronger 
contractions  than  kathodal  closure  (K.C.) ;  still  greater  degeneration 
is  shown  if  anodal  opening  (A.O.)  contractions  are  stronger  than 
either  of  the  above;  and  most  complete  degeneration  is  shown  by 
the  complete  reversal  of  the  normal  formulas  as  shown  by  distinct 
kathodal  opening  (K.O.)  contractions. 

Pathology  of  Reaction  of  Degeneration. — The  nerves  affected  show: 
(i)  Nuclei  swollen  and  granular,  (2)  the  white  substance  of  Schwann 
is  broken  up,  (3)  the  axis  cylinders  are  broken,  and  (4)  the  nerve  sub- 
stance becomes  a  fibrous  cord.  The  muscles  show :  (i)  Great  increase 
in  fibrous  tissue,  (2)  presence  of  granules,  (3)  atrophy  of  muscular 
fibers,  and  (4)  disappearance  of  the  transverse  striae. 

Sequels. — Among  the  deformities  resulting  from  the  paralysis  are 
the  different  forms  of  taHpes. 

Talipes  equinus,  the  result  of  paralysis  of  the  ant ero -external 
muscular  group  of  the  leg. 

Eqiiino-varus,  the  result  of  paralysis  of  the  antero-external  mus- 
cular group  of  the  leg,  together  with  the  adductors  of  the  foot. 

Talipes  calcaneus,  the  resiilt  of  paralysis  of  the  muscles  of  the  calf 
of  the  leg. 

Talipes  cavus — "pes  cavus" — characterized  by  the  hollowing  of 
the  sole  of  the  foot,  with  prominence  of  the  instep,  the  result  of 
paralysis  of  the  calf  muscles  with  contraction  of  the  long  flexor  of  the 
toe  or  the  long  peroneus — the  foot  flexors. 

Diagnosis. — The  recognition  of  acute  poHomyelitis  is  not  always 
possible  at  the  onset  or  during  the  early  days  of  its  course,  as  localized 
paralyses  are  difficult  of  detection  in  children,  but  immobility  of  one 
leg  or  arm  in  children  with  febrile  symptoms,  or  following  convulsions, 


ACUTE   POLIOMYELITIS  37 

is  always  an  indication  of  poliomyelitis.  After  the  initial  stage  has 
passed,  the  presence  of  paralysis,  wasting,  presence  of  R.D.  (reactions 
of  degeneration),  loss  of  reflexes,  and  the  absence  of  anesthesia,  render 
the  diagnosis  very  easy. 

Hemiplegia  from  acute  cerebral  affections  in  children  can  be  dis- 
tinguished from  infantile  paralysis  by  the  disorders  of  intelligence 
and  the  special  senses,  and  the  perseverance  of  the  normal  electro- 
contractility. 

Paralysis  of  myelitis  occurs  in  older  persons,  and  is  associated  with 
disturbances  of  the  genitourinary  organs  and  bed-sores. 

Pseudo-muscular  hypertrophy,  with  paralysis,  begins  gradually, 
becoming  progressively  worse  with  increase  in  the  size  of  the  limbs. 

Prognosis. — Except  in  cases  in  which  the  onset  is  very  severe,  the 
outlook  as  regards  life  is  generally  regarded  as  good;  but  in  some  epi- 
demics the  death  rate  is  high.  Morq  or  less  paralysis  with  muscular 
wasting  and  deformities  always  results,  but  by  its  early  recognition 
and  prompt  treatment  the  extent  may  be  greatly  lessened. 

Treatment. — During  the  febrile  stage  the  patient  should  be  placed 
at  rest  in  bed  and  all  the  secretions  rendered  free.  If  the  affection 
is  suspected  at  this  period,  the  limbs  should  be  wrapped  in  cotton- 
wool and  ergot  administered  to  lessen  the  spinal  congestion.  The 
nose  and  throat  must  be  kept  as  clean  as  possible;  gargling  with  2 
per  cent,  solution  of  hydrogen  peroxide  is  useful.  Counterirritation 
is  unnecessary.  As  soon  as  the  febrile  reaction  has  subsided  and  the 
paralysis  becomes  manifest  the  child  should  be  well  fed  and  taken  out- 
doors once  daily.  Urotropin,  in  doses  of  5  grains  every  three  or 
four  hours,  has  been  recommended.  Gentle  friction  should  be  applied 
to  the  affected  muscles  at  first,  followed  later  by  the  hot  spinal 
douche  and  mild  galvanism.  Internally,  quinine,  belladonna,  ergot, 
and  potassium  iodide  may  be  of  value.  Later,  as  improvement 
takes  place  tincture  of  nux  vomica,  TTlj  to  iij  (0.06  to  0.2  c.c),  three 
times  daily,  or  hypodermic  injections  of  strychnine  sulphate,  gr. 
Ke  to  3^00  (0.004  to  0.00065  gm.),  according  to  the  age,  twice  a 
week,  and  faradism  to  the  paralyzed  muscles  are  to  be  used.  Means 
should  be  taken  to  prevent  deformities.  It  must  be  borne  in  mind 
that  the  recovery  of  paralyzed  parts  and  the  restoration  of  lost 
muscular  power  and  function  is  a  process  which  extends  over  a  very 
long  period  of  time — months,  and  even  years. 


38 


RELAPSING  FEVER 
RELAPSING   FEVER 


Synonyms. — Febris  recurrens;  famine  fever;  spirillum  fever;  seven- 
day  fever. 

Definition. — An  acute,  infectious,  contagious,  epidemic,  febrile 
disease,  self-limited,  characterized  by  a  febrile  paroxysm,  lasting 
about  six  days,  succeeded  by  an  entire  intermission  of  the  same  dura- 
tion, which  is  in  turn  followed  by  a  relapse  similar  to  the  first  seizure. 


Fig.  7. — Clinical   chart   of   relapsing   fever  showing   the   febrile   movement   upon    the 
fourteenth  day.     {From   Wilcox's  Fever  Nursing.) 

Cause. — The  disease  is  due  to  the  SpirochcEta  Obermeieri,  a  cork- 
screw-shaped microorganism.  The  predisposing  factors  in  the 
production  of  this  disease  are  overcrowding,  bad  hygiene,  filth, 
poor  food,  impure  air,  and  destitution;  the  bed-bug,  body  louse,  and 
tick  are  beheved  to  be  common  means  of  spreading  the  disease. 

Pathological  Anatomy. — There  are  no  structural  changes  distinc- 
tive of  this  disease.  The  spleen  is  enlarged  and  usually  covered 
with  a  fresh  fibrinous  exudation;  and  the  splenic  pulp  is  softened 
and  shows  enlarged  Malpighian  bodies.  The  Hver  and  kidneys  are 
swollen  and  congested.  There  may  be  catarrhal  inflammation  of 
the  stomach  and  bile-ducts.  The  microorganisms  are  found  in 
the  blood  only  during  the  febrile  paroxysms  in  the  Hving  subject. 


MALTA   FEVER  39 

Symptoms. — The  onset  is  sudden  with  a  chill  followed  by  fever, 
T02°  to  io4°F.,  frequent,  rather  weak  pulse,  headache,  nausea,  vomit- 
ing, and  lancinating  pains  most  marked  in  the  back  and  the  calves 
of  the  legs.  On  the  second  day  there  is  a  sense  of  fullness  in  the 
upper  part  of  the  abdomen  due  to  swelling  of  the  liver  and  spleen. 
Jaundice  and  sweats  are  common.  The  fever  falls  by  crisis  on  the 
seventh  day  to  reappear  on  the  fourteenth  day,  but  with  less  severity. 
The  symptoms  then  continue  for  about  four  days  when  convalescence 
slowly  begins.     There  may  be  more  than  one  relapse. 

Complications. — Bronchitis,  pneumonia,  albuminuria,  hematuria, 
paralysis,  and  ophthalmia  are  the  more  frequent  complications. 

Diagnosis. — The  history,  temperature  record,  and  the  presence 
of  the  microorganisms  in  the  blood  (during  the  fever  only),  will 
serve  to  distinguish  this  affection  from  typhus, 
yellow  fever,  remittent  fever,  or  any  other  dis- 
ease with  which  it  may  be  confounded. 

Prognosis. — Recovery  is  the  rule  in  uncom- 
plicated cases. 

Treatment. — Prophylaxis  consists  in  freeing 
the  patient  from  bed-bugs  and  body  lice.  Im- 
mediate isolation  and  disinfection  are  necessary  pj^.  g.— Spirillum  of 
to  prevent  the  spread  of  the  disease.  Rest  in  chSta  0bermeflri)*'.'4h'e 
bed,  nutritious  and  easily  digested  food,  and  care-  organism  is usuaiiyionger 

'  _  .  than   IS   here   shown. 

ful  nursing  are  essential;  symptoms  are  treated   (From  Greene's  Medical 

..  .  ...    1  c^    1  Diagnosis.) 

as  they  arise,  on  general  principles.     Salvarsan 
(or  neosalvarsan)  should  be  injected  intravenously,  as  this  drug  is 
said  to  destroy  the  spirillum  of  relapsing  fever.     At  the  crisis  stimu- 
lants and  tonics  may  be  required,  specially  by  enfeebled  persons. 

MALTA  FEVER 

S3mon3ans. — Mediterranean  fever;  undulant  fever;  Neapolitan 
fever;  rock  fever;  Gibraltar  fever. 

Definition. — An  endemic  infectious  disease,  characterized  by  an 
irregular  fever,  profuse  sweats,  pain,  arthritis,  enlarged  spleen,  and 
a  tendency  to  relapse. 

Etiology. — It  is  due  to  the  micrococcus  melitensis  of  Bruce.  The 
infection  is  supposed  to  be  carried  by  goats'  milk;  formerly  the  air, 
water  and  mosquitos  were  put  forward  as  the  carriers  of  the  disease. 
It  chiefly  attacks  the  young  (between  six  and  thirty  years) . 


40  MALARIA 

Pathology. — The  liver  is  enlarged  and  congested,  the  spleen  is 
enlarged,  hyperemic  and  soft;  in  both  of  these  organs  the  micrococcus 
is  found  in  large  numbers.  The  lungs  and  intestines  may  also  be 
congested. 

Sjnnptoms. — The  period  of  incubation  is  from  six  to  ten  days. 
The  onset  is  slow,  with  headache,  restlessness,  prostration,  and  grad- 
ual rise  of  temperature  for  three  or  four  days.  There  may  be  epis- 
taxis  and  coated  tongue;  constipation  is  generally  present,  and  the 
spleen  is  enlarged.  A  profuse  sweat  occurs  at  night,  and  there  are 
sudamina,  but  no  rose-spots  or  tympanites.  As  the  temperature 
falls  to  normal  the  other  symptoms  abate  and  the  patient  feels  con- 
valescent, but  a  relapse  occurs,  and  the  symptoms  return,  often  with 
increased  severity.  After  another  three  or  four  weeks  there  is  an- 
other interval,  followed  by  another  relapse;  and  so  the  disease  goes 
on  and  may  be  prolonged  for  months. 

Complications  and  Sequelae. — Pneumonia,  neuralgia,  orchitis  and 
anemia. 

Prognosis  is  good;  the  death  rate  is  about  2  or  3  per  cent. 

Treatment. — This  is  symptomatic  and  supportive  and  somewhat 
on  the  lines  of  that  for  typhoid.  People  Hving  in  infected  regions 
should  not  use  the  milk  of  goats;  or,  if  no  other  is  available,  the  goat's 
milk  should  be  boiled. 

MALARIA 

Synonyms. — Ague;  fever  and  ague;  chills  and  fever;  marsh  fever; 
swamp  fever;  see  also  below,  under  remittent  fever  (page  47),  and 
pernicious  malarial  fever  (page  48). 

Definition. — An  infectious  fever,  intermittent  or  remittent  in 
type,  characterized  by  enlargement  of  the  spleen,  chills,  and  anemia 
and  due  to  the  Haemamoeba,  Plasmodium  malarice  of  Laveran. 
(Note. — This  is  a  protozoon,  not  a  bacterium.) 

Cause. — The  exciting  cause  is  the  microorganism,  already  men- 
tioned, which  gains  access  to  the  body  through  the  bites  of  mosquitos 
belonging  to  the  genus  anopheles.  The  predisposing  causes  are  those 
factors  that  favor  mosquito  life,  namely,  marshy  districts,  high  tem- 
peratures, humidity,  and  absence  of  winds.  On  account  of  the  noc- 
turnal habits  of  the  anopheles  the  disease  is  more  Hkely  to  be  con- 
tracted at  night.  It  should  be  noted  that  mosquitos  do  not  cause 
malaria  but  they  carry  it  from  those  who  have  it  to  those  who  do  not 
have  it. 


MALARIA 


41 


There  are  three  varieties  of  mosquitos  which  are  of  medical  interest 
fe    and  the  following  table  (from  Jackson's  Tropical  Medicine)  will  be 
found  helpful  to  the  practitioner  and  the  student. 


Culex                 1            Stegomyia             j            Anopheles 

Diseases 
conveyed. 

Mostly         nonpatho- 
genic   for    man    but 
may    convey    filaria] 
diseases. 

Stegomyia        fasciata 
conveys             yellow 
fever  in  man. 

Conveys  malarial  dis- 
ease.    Conveys      fil- 
arial disease  in  man. 

Breeds 

In  and  about  houses, 
gardens,  back  yards, 
old    flower    pots,    or 
tins,     vessels,     tubs, 
cisterns,  barrels,  gut- 
ters, drains. 

"Home  bred." 

Resembles  Culex 

Puddle         breeding — 

shallow,  small  pools, 
in  rock  or  soil,   also 
at   margins   of   lakes 
and      rivers,       quiet 
bays,   ponds,   in  rice 
fields       and       water 
covering    submerged 
grass. 
Less  "home  bred." 

Bites 

By  day  or  night — at 
twilight.         Females 
only. 

Often    bites    by    day. 
Females  only. 

Nocturnal          chiefly. 
Females  only. 

Wings 

Rarely  spotted 

Never  spotted 

Usually             spotted. 

There  are  a  few  ex- 
ceptions. 

Larval  motility. . 

Larvae       float       with 
heads         downward. 
When           disturbed 
wriggle  to  bottom  of 
vessel. 

Resemble  Culex 

Float    at    surface    of 
water  like  sticks  and 
have     a     backward, 
skating  motion. 

Resting  posture. 

"  H  u  n  c  h-b  a  c  k  e  d. " 
Axis     of     head     and 
proboscis    forms    an 
obtuse     angle     with 
body. 

Resembles  Culex 

Axis  of  head,  probos- 
cis and  body  in  same 
line.     Appears    as   if 
standing  on  its  head. 
Some    exceptions    to 
this  rule. 

Eggs 

Deposited    in    ellipse- 
shaped  masses,   con- 
vex   below,    concave 
above     (boat     shap- 
ed).    Eggs  arranged 
in  rows,  perpendicu- 
lar    and      adherent, 
have      one      pointed 
end.          Color    dirty 
white,  200  to  400  in 
a  batch. 

Egg's    are    more    oval 
and    are    not    depos- 
ited     in      rafts      or 
masses.    Float  singly 
upon   their   sides,   or 
sink,    hatching    sub- 
merged. 

Deposited    in    masses 
of    40    to    100    eggs, 
not    adherent,     each 
egg    floating    on    its 
side,     and    regularly 
elliptic  in  outline,  at 
middle   of   each   side 
appears     a     clasping 
wrinkled  membrane. 
Dark  in  color. 

Singing  tone.  .  .  . 

High  pitched 

Resembles  Culex 

Low  pitched. 

Bodies 

Duirgray  in  color. . .  . 

Body  and  legs  cover- 
ed with  black  scales 
and   white   markings 
in     spots     or     lines. 

S.  Fasciata  has  trans- 
verse    striations     on 
ventral      aspect      of 
body. 

Dark  gray  or  brown. 

42  MALARIA 

Three  forms  of  the  microorganism  have  been  recognized.  The 
first  or  tertian  parasite  (the  Plasmodium  vivax)  is  characterized  in  the 
early  period  by  small-hyahne  bodies  possessed  of  ameboid  movements. 
At  first  they  occupy  but  a  few  of  the  red  blood  cells  but  as  they 
increase  in  size  and  number  they  become  filled  with  pigment  granules. 
As  the  organism  enlarges  the  pigment  collects  toward  the  center  and 
the  ameboid  movements  cease.  Segmentation  then  begins  and  the 
parasite  divides  into  from  12  to  24  parts  or  spores.  The  already  dis- 
tended blood  cell  now  ruptures,  discharging  the  spores  into  the  blood 
stream.  This  cycle  is  repeated.  The  chills  occur  simultaneously 
with  the  discharge  of  the  spores.  For  the  completion  of  this  cycle 
forty-eight  hours  are  usually  required,  so  that  a  single  group  of  these 
parasites  induces  a  paroxysm  every  other  day  {tertian  fever) .  The 
presence  of  two  distinct  groups  sporulating  on  alternate  days  gives 
rise  to  a  daily  paroxysm  {quotidian  fever) . 

The  second  form  or  quartan  parasite  (the  Plasmodium  malarice)  has 
less, pigment,  of  a  more  coarse  quality,  less  spores,  and  its  segmenta- 
tion requires  seventy-two  hours.  One  group  will  cause  a  paroxysm 
every  third  day  (with  an  intermission  of  two  days)  {quartan  fever) ; 
two  groups  sporulating  on  two  successive  days,  the  paroxysms  will 
occur  on  two  successive  days  being  separated  by  an  interval  of  one 
day  {double  quartan  fever).  In  the  presence  of  three  such  groups, 
daily  paroxysms  will  occur  {quotidian  fever) . 

The  third  or  estivo-autumnal  parasite  (the  Plasmodium  prcecox)  is 
smaller,  being  about  one-half  the  size  of  a  red  blood  cell,  and  contains 
less  pigment  than  the  preceding.  Within  the  blood  cells  it  appears 
as  a  group  of  small  hyaHne  bodies  and  soon  causes  the  corpuscles 
containing  it  to  assume  a  shrunken,  crenated,  and  brassy  appear- 
ance. After  a  week  or  more  large  ovoid  bodies,  crescentic  in  shape, 
appear  in  the  corpuscles.  Segmentation  occurs  only  in  the  spleen 
and  other  internal  organs.  The  entire  cycle  of  this  parasite  covers 
forty-eight  hours. 

Flagellated  forms  are  sometimes  observed  and  are  beheved  to  be 
concerned  in  the  reproduction  of  these  organisms. 

In  the  United  States  the  tertian  is  the  common  form,  the  quartan 
being  rare;  these  two  are  rarely  fatal  and  respond  readily  to  quinine. 
The  estivo-autumnal  is  found  in  the  tropics,  is  more  fatal,  has  a  more 
irregular  course,  and  does  not  respond  so  readily  to  quinine. 

Strictly  speaking,  the  term  Plasmodium  malarice  belongs  only  to 
the  parasite  of  quartan  fever;  the  parasite  of  tertian  fever  being  the 


MALARIA 


43 


Plasmodium  vivax;  and  that  of  estivo-autumnal  fever  being  the 
Plasmodium  prmcox.  But  the  term  Plasmodium  malarice  is  often, 
loosely jTapplied  to  all  varieties. 


Day.     1 


SINGLE  TERTIAN  INFECTION. 
Paroxysm  every  third  day. 

P.  P.  P. 

*  »  » 


V- 

10       11 


12       1.3 


Day.    I 


DOUBLE  TERTIAN  INFECTION. 
Dally  paroxysm. 
P.        P.        P.        P.        P.        P.        P.        p 


P. 

». 


Day.     1  2 


SINGLE  QUARTAN  INFECTION. 

Paroxysm  every  fourth  day. 
?  P.  p. 


12        13 


P. 


DOUBLE  QUARTAN  INFECTION. 
Paroxysm  on  two  successive  days  with  oae  day's  Intermission. 
P  P         P  P.        P.  P.        P. 


P. 


X)ay.    1 


12       13 


14 


P.        P. 


TRIPLE  QUARTAN  INFECTION. 
Daily  paroxysm. 
P-        P.        P.        P.        P.       P.       P.        P. 


Day.    1 

CHART  ILLUSTRATING  THE  DIFFERENT  TYPES  OF  FEVER 
RESULTING  FROM  INFECTION  WITH  SINGLE  AND  WITH 
MULTIPLE   GROUPS  OF   MALARIAL   PARASITES. 

The  duration  of  the  parasites'  cycle  of  development 
is  expressed  by  colored  lines,  thus: 
Black:    First    grQup   of  parasites. 
Red:      Second.  "        "       •;    " 
Blue:    Third       "        '•       "    " 
P:  Paroxysm. 

Fig.  9. — (From   Da   Cosla's   Clinical   Hematology.) 

Pathological  Anatomy. — Disintegration  of  the  blood  cells  is  the 
most  marked  feature  of  the  acute  forms,  while  in  the  chronic  forms 
permanent  enlargement  of  the  spleen  from  overgrowth  of  fibrous 
tissue  is  a  common  result. 


44 


INTERMITTENT   FEVER 


Varieties. — The  principal  forms  of  malaria  are  intermittent  fever, 
remittent  fever,   and  pernicious  malaria. 

Diagnosis. — This  is  made  absolutely  by  the  presence  of  the  Plas- 
modium; other  diagnostic  points  are  the  presence  of  pigmented 
leukoc5rtes,  a  mononuclear  leukocytosis,  an  enlarged  spleen,  and  re- 
sponse to  quinine. 

INTERMITTENT  FEVER 

Intermittent  fever  is  a  variety  of  malaria,  characterized  by  a  cold, 
a  hot,  and  a  sweating  stage,'Jollowed  by  an  interval  of  complete 


Fig.  10. — Metamorphosis  of  mosqmtos.  i,  2,  3,  4  and  5,  Eggs,  larva,  pupa  and 
heads  of  male  and  female  Culex;  6,  7,  8,  9  and  10,  eggs,  larva,  pupa  and  heads  of  male 
and  female  Anopheles;  11,  12,  13,  14  and  15,  eggs,  larva,  pupa  and  heads  of  male  and 
female  Stegomyia.     {From  Stitt's  Practical  Bacteriology.) 

intermission  or  apyrexia,  varying  in  length  according  to  the  character 
and  group  of  the  malarial  organism. 

Sjmiptoms. — The  cold  stage  begins  with  lassitude,  yawning,  head- 
ache, and  nausea,  followed  by  a  severe  chill  in  which  the  teeth  chatter, 
the  skin  becomes  pale,  cold,  and  rough  {cutis  anserina),  the  nails 
and  lips  are  blue,  and  the  features  are  pinched.     There  is  great 


INTERMITTENT   FEVER 


45 


thirst  and  the  thermometer  shows  a  rise  of  temperature  to  102°  to 
io4°F.     These  phenomena  last  from  one-half  hour  to  an  hour. 

The  hot  stage  begins  as  the  shivering  ceases  and  the  temperature 
rises  still  higher,  io6°F.  or  more.  The  body-surface  becomes  hot 
and  flushed,  and  the  pulse  becomes  rapid  and  full.  Headache, 
backache,  nausea,  and  intense  thirst  are  also  present.  The  urine  is 
scanty,  high-colored,  and  of  increased  specific  gravity.  This  stage 
lasts  from  one  to  ten  hours. 


DAY  OF 
DISEASE 

1 

2     3 

4     6 

6 

n 

n 

n 

n 

n 

n 

n 

1         0 

-42 

HOUR 

A    f 

M  ^ 

A    P  aIf 
M  M  m|n 

A   P  a   F 
1  M  M  M  » 

A   P 

K  M  M 

A 
M 

P 
M 

A 
M 

P 
M 

A   P 
MM 

A 
M 

P 
M 

A 
M 

P 
M 

A 

M 

P 
M 

A 
M 

P 
M 

A 

M 

P 
M 

A 
M 

P 
M 

A 
M 

P 
M 

A 
M 

P 
M 

A 

M 

P 
M 

A 
M 

P 
M 

A 
M 

P 
M 

A 
M 

P 
M 

107° 

-41°  H 

:       w 

106° 

105° 

1  104' 

^40°  B 
:        c 

•g  103' 

a  102° 

-39°  1 

:  Si 
:       3 

3 

%    101° 

j                L 

3  10« 

^38"^ 

99 

_  _       p. 

•^7 

98" 

97° 

-36° 

96' 

1 

1— 

1 — 

L 

1 — 

1— 

1_ 

1— 

1— 

1— 

1 — 

1—1 — 

1 — 

1— 

1 — 

L- 

1— 

1 — 

1 — 

Pig.  II. — Clinical  chart  of  ordinary  or  tertian  malaria  showing  three  febrile  paroxysms 
occurring  on  alternate  days.     {From  Wilcox's  Fever  Nursing.) 

The  sweating  stage  begins  gradually,  appearing  first  on  the  forehead 
and  gradually  extending  over  the  entire  surface  of  the  body.  All 
the  symptoms  subside  as  the  perspiration  becomes  free.  This 
period  lasts  from  one  to  four  hours  and  is  often  followed  by  a  re- 
freshing sleep. 

An  intermission,  of  varying  length,  then  occurs  after  which  another 
attack  begins,  being  ushered  in  with  chilliness  or  pain. 

Intermittent  fever  is  attended  by  enlargement  of  the  spleen, 
anemia,  and  pigmentation  of  the  leukocytes  but  no  increase  in  their 
number.  It  may  be  mistaken  in  a  hasty  examination  for  hectic 
fever,  pyemia,  or  nervous  chills  but  the  finding  of  the  organism  in 
the  blood  will  correct  any  error  in  diagnosis. 


46  INTERMITTENT   FEVER 

Prognosis. — Recovery  is  the  rule  with  treatment.  Neglected 
cases  may  terminate  favorably  after  several  paroxysms  but  are  more 
likely  to  pass  over  into  chronic  malaria  or  malarial  cachexia. 

Treatment. — The  cold  stage  may  be,  to  a  large  extent,  averted 
by  the  hypodermic  injection  of  morphine  sulphate,  gr.  3^  to  ^ 
(0.008  to  0.016  gm.),  or  pilocarpine  hydrochloride,  gr.  3^  (0.008  gm.), 
or  by  the  internal  administration  of  spirit  of  chloroform,  f  5  j  (4  c.c). 
During  the  hot  stage  cool  drinks  and  cool  sponging  are  indicated, 
and  during  the  sweating  stage  the  patient  should  be  sponged  with 
alum  and  hot  water. 

In  the  intermission  the  bowels  should  be  opened  by  the  administra- 
tion of  5  gr.  (0.32  gm.)  each  of  calomel  and  sodium  bicarbonate 
followed  by  an  active  saline  cathartic. 

Quinine  is  a  specific  for  this  disease.  Quinine  sulphate,  gr.  x  to 
XX  (0.65  to  1.30  gm.),  should  be  given  in  solution  or  capsules  in  one 
or  two  doses,  three  to  five  hours  before  the  expected  paroxysm. 
Other  preparations  of  cinchona  may  also  be  used. 

After  the  paroxysms  have  been  broken  up  the  solution  of  potassium 
arsenite  (Fowler's  solution),  TIlv  to  x  (0.3  to  o.O  c.c),  or  the  tincture 
of  the  chloride  of  iron,  TTtxx  (1.3  c.c.)  should  be  given  every  four  hours 
over  an  extended  period.  :. 

I^.     Perri  reducti, 

Quininse  sulphat aa  gr.  Ix  4.0      gm. 

Acidi  arsenosi gr.  j  0.065  gni- 

01.  pip.  nigr TTlxv  i  .0      c.c. 

M.  Ft.  pil.  No.  XXX. 

S. — One  pill  after  meals,  continued  for  one  month  or  longer. 

Relapses  being  common,  it  is  well  to  administer  quinine  on  the 
second  or  third  day,  fourth  to  the  sixth,  twelfth  to  the  fourteenth, 
and  nineteenth  to  the  twenty-first  days  after  the  last  paroxysm. 

Preventive  Measures. — The  prevention  of  the  disease  has  largely 
to  do  with  exterminating  mosquitos  and  avoiding  infection  of  them 
and  by  them.  The  draining  of  stagnant  pools  and  swamps  with  their 
subsequent  filHng  up  is  well  recognized  as  an  effective  measure. 
The  use  of  crude  petroleum  over  such  surfaces  has  been  found  to 
destroy  the  larvae  of  the  anopheles  in  from  two  to  four  weeks  and 
where  practicable  it  should  be  employed.  The  screening  of  the  pa- 
tient and  other  individuals  in  malarial  districts,  during  the  sleeping 
hours,  by  means  of  ordinary  netting  is  extremely  efficacious.     Sleep- 


REMITTENT   FEVER  47 

ing  on  low  ground,  unprotected,  should  be  avoided.     A  daily  dose  of 
from  5  to  10  gr.  of  quinine  sulphate  is  an  additional  protection. 

REMITTENT  FEVER 

Synonyms. — Bilious  fever;  bilious  remittent  fever;  marsh  fever, 
typho-malarial  fever;  estivo-autumnal  fever. 

Definition. — A  paroxysmal  fever,  with  exacerbations  and  remis- 
sions in  which  the  temperature  is  constantly  above  the  normal; 
characterized  by  a  moderate  cold  stage  (which  does  not  recur  with 
each  paroxysm);  an  intense  hot  stage,  with  violent  headache  and 
gastric  irritability;  and  an  almost  imperceptible  sweating  stage, 
which  is  frequently  wanting. 

This  variety  of  malaria  lasts,  as  a  rule,  from  seven  to  fourteen 
days,  and  usually  occurs  during  the  late  summer  and  early  autumn. 
Frequently  the  fever  fails  to  remit  and  becomes  continuous  in  type. 

The  characteristics  that  serve  to  distinguish  this  affection  are  the 
temperature  record  and  the  presence  of  the  estivo-autumnal  parasite 
already  described;  the  crescents  are  pathognomonic.  The  spleen 
is  always  enlarged  and  there  may  be  jaundice  and  delirium. 

Prognosis. — Uncomplicated  cases  usually  recover,  but  the  disease 
may  pass  over  into  malarial  cachexia  or  be  followed  by  persistent 
headache  and  vertigo. 

Treatment. — Quinine  sulphate,  gr.  xvj  (i  gm.)  a  day,  should  be 
administered  by  the  mouth  or  rectum;  or  the  bisulphate  of  quinine 
may  be  given  hypodermically  during  the  remission.  The  following 
should  also  be  given  during  this  period : 

I^.     Hydrargyri  chlor.  mitis gr.  v  0.3      gm. 

Sodii  bicarb gr.  v  0.3      gm. 

Pulv.  ipecac gr.  ss  o .  03    gm. 

M.  S. — To  be  taken  as  required  according  to  the  condition  of 
the  intestinal  tract. 

During  the  hot  stage  the  patient  should  be  sponged  and  an  ice-bag 
placed  on  the  head.  If  there  is  a  tendency  to  cerebral  congestion  dry 
or  wet  cups  should  be  applied  to  the  nape  of  the  neck  and  the  follow- 
ing mixture  given: 

I^.     Tinct.  aconit Tllv  o .  3  c.c. 

Liq.  ammon.  acetat f  5ij  8.0  c.c. 

Liq.  potassii  citrat f3ij  8.0  c.c. 

M.  S. — Every  two  hours. 


48  PERNICIOUS   MALARIAL   FEVER 

The  treatment  advised  in  intermittent  fever  is  also  applicable  to 
this  variety  of  malaria. 

PERNICIOUS  MALARIAL  FEVER 

Synonyms. — Congestive  fever;  malignant  intermittent  fever; 
malignant  remittent  fever;  the  congestive  chill. 

Definition. — A  malignant  malarial  fever,  which  may  be  of  the 
intermittent  or  remittent  type;  characterized  by  intense  congestion 
of  one  or  more  internal  organs,  together  with  dangerous  perversion 
of  the  functions  of  innervation. 

It  occurs  almost  exclusively  in  warm  climates  and  is  due  to  the 
estivo-autumnal  parasite.  As  a  rule  the  pernicious  character  of  the 
disease  does  not  become  manifest  until  after  the  second  or  third 
paroxysm. 

S3nnptoms. — The  disease  begins  as  intermittent  or  remittent  fever, 
but  with  the  migration  of  the  parasites  new  groups  of  symptoms  arise 
according  to  the  localization  of  the  organisms. 

The  gastroenteric  type  is  characterized  by  intense  nausea,  vomiting, 
purging  of  thin  discharge  mixed  with  blood,  tenesmus,  burning 
sensations  in  the  stomach,  intense  thirst,  frequent  weak  pulse,  cold 
hands,  feet  and  face,  shrunken  features,  cramps,  and  marked  depres- 
sion.    It  lasts  from  one-half  to  several  hours. 

The  thoracic  type  is  usually  combined  with  the  preceding  and  is 
attended  by  marked  dyspnea,  oppressed  cough  with  blood-streaked 
sputa,  frequent  weak  pulse,  cold  surface,  and  terror-stricken  features, 
all  of  which  arise  from  the  intense  pulmonary  congestion. 

The  cerebral  type  is  marked  by  violent  delirium,  followed  by  stupor 
and  coma,  slow  full  pulse,  and  a  flushed  or  livid  surface  due  to  con- 
gestion of  the  brain. 

The  hemorrhagic  type  is  caused  by  disintegration  of  the  blood  and  is 
characterized  by  hemorrhages  from  the  mucous  membranes  and  into 
the  subcutaneous  tissues,  bloody  urine  and  jaundice. 

The  algid  type  is  that  in  which  the  body-surface  is  intensely  cold, 
the  rectal  temperature  ranging  from  104°  to  io7°F.,  a  cold  sweat 
covers  the  body,  the  pulse  is  slow,  feeble,  and  often  absent  at  the 
wrist,  there  is  intense  thirst,  the  mind  is  clear,  and  the  countenance 
is  death -hke. 

These  various  types  usually  exist  more  or  less  combined. 

Diagnosis. — The  predominance  of  certain  of  these  groups  of 
symptoms  may  cause  the  disease  to  be  mistaken  for  cerebral  apo- 


PERNICIOUS   MALARIAL   FEVER  49 

plexy,  meningitis,  uremia,  yellow  fever,  or  cholera,  but  a  careful 
examination  of  the  blood  will  reveal  the  characteristic  parasite  which 
is  pathognomonic  of  malaria. 

Prognosis. — The  disease  continues  from  a  few  hours  to  one,  two, 
or  three  days  and  unless  controlled  prior  to  the  second  paroxysm 
is  unfavorable.  The  intermittent  forms  are  most  favorable.  The 
mortality  is  about  13  per  cent. 

Treatment. — The  patient  should  be  cinchonized  immediately  by 
the  hypodermic  injection  of  40  gr.  (2.6  gm.)  of  the  bisulphate  or 
bihydrochloride  of  quinine. 

The  muriate  of  quinine  and  urea  in  10,  15  or  20  gr.  (0.66,  i,  and 
1.33  gm.)  doses  is  also  highly  recommended  for  hypodermic  use; 
and  so  is  the  following: 

I^.     Quininaehydrochloridiacidi  (B.P.)  gr.  xx     1.2      gm. 

Aquae  distillatae HIxv       i  .  00    c.c. 

M.  This  fills  an  ordinary  hypodermic  syringe  and  is  a  full  dose. 

Intramuscular  injection  is  said  to  be  less  painful  than  subcutaneous 
injection. 

Methylene  blue,  in  dose  of  3  gr.  (o.i  gm.)  every  three  hours,  in 
pill  or  capsule,  has  also  been  used.  Care  must  be  taken  to  secure  a 
pure  drug. 

''Warburg's  tincture,"*  has  considerable  reputation  in  the  various 
forms  of  malarial  fevers.     It  can  be  given  in  doses  of  half  an  ounce- 
and  repeated  in  three  hours;  it  is  a  powerful  sudorific  and  can  be 
prescribed  either  "with  aloes"  or  "without  aloes." 

In  the  cold  stage,  heat  and  stimulating  lotions  should  be  applied 
to  the  body-surface;  while  in  the  hot  stage,  cold  should  be  employed 
and  morphine  administered  hypodermically. 

In  the  gastroenteric  type  Da  Costa  recommends: 

I^.     Morph.  sulphat gr.  M  0.016  gm. 

Pulv.  camph gr.  j  '      o .  065  gm. 

Mass.  hydrarg gr.  ij  o.  12    gm. 

Pulv.  capsici gr.  ss  o .  03    gm. 

M.  S. — Every  half  hour  until  the  character  of  the  stool  is  changed. 

For  the  thoracic  type,  dry  or  wet  cups,  carbonate  of  ammonium, 
caffeine,  and  strychnine  are  indicated,  while  for  the  cerebral  type 
venesection,  cups  or  leeches  to  the  neck,  cold  to  the  head,  and  prompt 

*  For  the  original  (or  supposed  original)  formula  of  this  preparation,  see  9th   edition 
of  this  work.     It  has  only  an  historic  interest. 
4 


50  BLACKWATER   FEVER 

purgation,  diuresis,  and  diaphoresis  are  required.  For  the  algid 
type,  morphine  and  atropine,  hypodermically,  ammonium  carbonate 
and  alcohoHc  stimulation  are  necessary;  but  in  the  hemorrhagic 
variety,  morphine,  turpentine,  dilute  sulphuric  acid,  gallic  acid, 
Monsel's  solution,  and  the  following  are  indicated: 

I^.     Fluidextracti  ergotae f§ss  15  c.c. 

Acid,  sulphuric,  dil f 5jss  6  c.c. 

Acid,  gallic 5  4  gm. 

Syr.  zingib f  3iij  12  c.c. 

Aquae q.  s.  ad  f§iij  ad        90  c.c. 

M.  S. — Dessertspoonful  every  four  hours,  well  diluted. 

Malarial  cachexia  may  result  as  a  sequel  to  any  of  the  forms  of 
malaria  just  described.  The  patient  is  more  or  less  jaundiced,  the 
circulation  is  poor,  the  temperature  is  usually  subnormal,  but  there 
may  be  periodical  attacks  of  fever,  the  spleen  is  enlarged,  and  weak- 
ness and  emaciation  are  marked.  Neuralgia,  headache,  hematuria, 
paraplegia,  and  orchitis  may  manifest  themselves. 

In  the  treatment  of  this  condition  iron,  quinine,  strychnine,  arsenic, 
and  cod-liver  oil  should  be  administered  over  an  extended  period. 
Occasional  cinchonism  is  also  necessary. 

BLACKWATER  FEVER 

S3mon3mis. — Hemoglobinuric  fever;  malarial  hemoglobinuria,  or 
hematuria. 

Definition. — A  tropical  disease  of  unknown  origin,  characterized 
by  a  hemolysis,  generally  of  short  duration,  and  tending  to  recovery 
unless  complications  (such  as  suppression  of  urine)  occur. 

Etiology. — This  is  unknown ;  there  are  three  theories :  ( i )  That  it  is 
malarial;  (2)  that  it  is  due  to  quinine  poisoning;  and  (3)  that  it  has  a 
specific  origin  not  yet  determined. 

Symptoms. — The  onset  is  usually  abrupt,  with  occasionally  fever 
and  malaise  as  prodromata;  it  begins  with  a  rigor,  rapid  rise  of  tem- 
perature, headache,  backache,  and  vomiting.  Micturition  is  apt  to 
be  painfull  For  a  few  days  the  temperature  is  intermittent  but  tends 
to  rise,  the  maximum  being  reached  about  the  third  day,  when  the 
hemoglobinuria  appears.  This  is  followed  by  jaundice  and  accom- 
panied by  thirst,  vomiting,  polyuria,  frequent  micturition;  later 
there  may  be  retention  or  even  suppression  of  urine.  The  latter 
event  is  fatal.     Anemia  is  present  and  may  be  extreme. 


YELLOW   FEVER  5 1 

Diagnosis. — This  is  made  from  the  urine,  which  is  practically 
black,  and  contains  hemoglobin;  this  latter  should  be  sought  with 
the  aid  of  the  spectroscope.  The  vomiting  and  icterus  are  important 
diagnostic  symptoms. 

Treatment. — Water  should  be  freely  administered;  quinine  is  use- 
less, unless  the  malarial  parasite  is  found  in  the  blood.  Begin  with  a 
purge;  give  ice  to  suck;  apply  counterirritants  to  the  epigastrium; 
sustain  the  strength  by  nutrient  enemata  and  alcohol.  It  must  be 
remembered  that  the  disease  is  not  hemorrhagic  in  character,  but 
hemolytic. 

YELLOW  FEVER 

Synonyms. — Yellow  Jack;  bilious  malignant  fever;  typhus  icter- 
oides;  Mediterranean  fever;  sailor's  fever;  black  vomit. 

Definition. — An  acute,  infectious,  paroxysmal  disease,  of  three 
stages — the  febrile,  the  remission,  and  the  collapse;  characterized 
by  violent  fever,  yellowness  of  the  surface,  albuminuria,  and  marked 
tendency  to  hemorrhage  especially  in  the  stomach,  causing  the 
"black  or  coffee-ground  vomit." 

Cause. — The  disease  is  in  all  probability  caused  by  an  ultramicro- 
scopic  organism  which  has  not  yet  been  determined.  But  the  inter- 
mediate host  is  a  mosquito — Stegomyia  fasciata — and  it  is  by  means 
of  this  mosquito  that  the  disease  is  transmitted.  There  is  no  longer 
any  ground  for  the  belief  in  the  transmission  of  yellow  fever  by 
fomites.  For  description  of  and  differentiation  of  the  stegomyia 
from  other  mosquitos,  see  above,  page  41.  No  race,  age,  or  sex  is 
exempt  from  the  disease.  One  attack  confers  immunity,  as  a  rule. 
It  is  essentially  a  tropical  disease  and  is  most  common  during  June, 
July,  August,  and  September.  The  natives  of  warm  countries, 
especially  the  negroes,  enjoy  comparative  immunity  to  the  disease 
but  strangers  are  particularly  susc(;ptible. 

Guiteras  mentions  three  areas  of  infection:  i.  The  focal  zone,  in 
which,  up  to  1 90 1,  the  disease  was  never  absent,  including  Havana, 
Vera  Cruz,  Rio,  and  other  Spanish-American  ports.  2.  Peri-focal 
zone  or  regions  of  periodic  epidemics,  including  the  ports  of  the  tropical 
Atlantic  in  America  and  Africa.  3.  The  zone  of  accidental  epidemics, 
between  the  parallels  of  45°  north  and  35°  south  latitude. 

Pathological  Anatomy. — Dissolution  of  the  red  blood  cells  and 
granular  degeneration  of  the  viscera  are  the  most  prominent  struc- 
tural changes.     Jaundice,  hemorrhages,  and  fatty  degeneration  follow 


52 


YELLOW   FEVER 


these  changes.  A  diagnosis  cannot  be  made  from  the  post-mortem 
lesions  as  none  of  them  is  distinctive. 

Sjrmptoms. — An  incubation  period  of  from  twenty-four  hours  to 
six  days  precedes  the  attack. 

The  first  stage  or  febrile  stage  is  ushered  in  with  malaise,  headache, 
anorexia,  or  chill,  followed  by  high  fever,  reaching  shortly  104°  to 


QAY  OF 

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Fig.   12. — Clinical  chart  of  a  yellow-fever  patient  showing  the  pulse  typically   slow  in 
comparison  to  the  height  of  the  temperature.     {From   Wilcox's  Fever  Nursing.) 


io6°F.,  with  pains  in  the  head,  limbs  and  back.  The  attack  usually 
begins  at  night.  The  pulse  is  rapid,  the  face  is  flushed,  the  eyes  are 
bright,  and  the  stomach  is  irritable.  Vomiting  is  a  characteristic 
symptom.  As  the  temperature  rises  the  pulse  is  at  first  more  rapid 
but  later  shows  a  marked  tendency  to  fall,  a  feature  pecuHarly  charac- 
teristic.    The  patients  are  restless  and  anxious,  and  extremely  pros- 


YELLOW    FEVER  53 

trated.  The  urine  is  scanty,  high-colored,  acid,  and  contains 
albumin.  Constipation  is  present.  A  peculiar  and  'Characteristic 
odor  is  emitted  from  the  patient.  The  first  stage  lasts  from  thirty- 
six  hours  to  three  or  four  days,  during  the  latter  part  of  which 
the  body  becomes  slightly  icteroid.  In  severe  attacks  delirium  is 
frequent. 

The  second  stage  is  that  in  which  the  fever  remits,  the  temperature 
decHning  to  100°  or  99°F.  All  the  distressing  symptoms  abate  and 
the  affection  may  terminate  by  crisis  but  more  frequently  after  an 
interval  varying  from  a  few  hours  to  one  or  four  days  it  passes  into 
the  third  stage. 

The  third  stage,  or  that  of  secondary  fever,  is  ushered  in  by  a  return 
of  all  the  symptoms  in  an  exaggerated  form,  followed  by  jaundice, 
which  passes  into  a  deep  mahogany  color,  black  vomit,  hemorrhages 
from  the  mucous  membranes,  feeble  pulse,  cold  surface,  irregular 
respiration,  and  death  from  exhaustion,  the  mind  remaining  clear 
until  the  end.  Recovery  may  occur  even  after  the  appearance  of 
black  vomit. 

Diagnosis.- — According  to  Guiteras  the  distinctive  features  of 
this  disease  are:  Early  jaundice;  characteristic /acie^,*  albuminuria, 
which  shows  itself  even  in  mild  cases,  on  the  second,  third,  or  fourth 
day;  slowing  of  the  pulse  as  the  temperature  rises,  most  noticeable 
on  the  second  or  third  day;  and  a  high  hemoglobin  estimate  (90  or 
more)  at  the  beginning  of  the  disease. 

Dengue  may  be  mistaken  for  yellow  fever  but  it  lacks  the  distinc- 
tive features  just  enumerated.  In  view,  however,  of  the  importance 
of  the  subject,  as  well  as  of  the  possibility  of  the  coexistence  of  dengue 
and  yellow  fever,  the  following  table  of  differential  diagnosis  (from 
Jackson's  Tropical  Diseases)  is  appended  (see  page  54). 

Remittent  fever  may  be  distinguished  by  the  presence  of  the  malarial 
microorganism  in  the  blood  and  the  therapeutic  test. 

Acute  yellow  atrophy  of  the  liver  resembles  yellow  fever  closely  but 
the  history,  pulse,  temperature,  and  presence  of  leucin  and  tyrosin 
in  the  urine  will  serve  to  differentiate  the  former  from  the  latter. 

Prognosis. — The  disease  seldom  lasts  more  than  one  week.  High 
fever,  collapse,  black  vomit,  and  suppression  of  urine  are  unfavorable 
symptoms.  The  mortality  ranges  from  15  to  85  per  cent.  Accord- 
ing to  Manson,  the  prognosis  is  better  for  women  and  children  than 
for  men;  better  for  old  residents  than  for  new-comers;  worst  of  all 
for  the  intemperate. 


54 


YELLOW    FEVER 


Temperattire. . 


Duration   of 
fever. 


Incubation. 


Vomiting. 


Pulse. 


Jaundice . 


Eruptions . 


Urine. 


Fever  of  one  paroxysm,  as  Fever  of  two  parox- 
a  rule.  High  tempera-:  ysms  and  a  remis- 
ture  for  3  days.  sion,     as     a     rule. 

Fever  high  in  first 
I     period;  low  in  sec- 
ond. 


Fever  of  several 
paroxysms  with 
remissions  or  in- 
termissions. Mod- 
erate temperature, 
as  a  rule. 


3  to  7  days !  5  to  8  days. 


Human  incubation,  i  to  6 
days.  Mosquito  incuba- 
tion about  12  days. 


Short  incubation,  i 
to  5  days;  average 
less  than  3  days. 


Variable     duration. 
May  last  weeks. 


Human  incubation, 
I  to  several  days. 
Mosquito  incuba- 
tion, about  10  days. 


Very  common  symptom —  Not  common.  BU-;  May  or  may  not  be 
both  bilious  and  hem-  ious  vomiting  in  present.  Bilious 
orrhagic  (black  vomit).        1     some  cases.  in  character. 


At  first,  rapid  and  bound-    Corresponds      with    Corresponds      with 
ing;       later,       abnormally     febrile       tempera-     febrile       tempera- 
slow  and  soft.     Does  not     ture. 
correspond  -  with  tempera- 
ture. 


ture. 


Characteristic 
stant. 


and 


con-'  Rare :  Subicteric   jaundice 

'  1     rather  common. 


Rare    and    not    character-!  Common    and    dis-!  Rare  and  not  char- 
istic.  i     tinctive.  '     acteristic. 


Mentality. 


Hemorrhagic 

symptoms. 


Scanty;  often  completely  Quantity  ample.  Not  usually  albu- 
suppressed,  and  albumin-  Rarely  albumin-:  minous  nor  sup- 
ous  from  early  stages.  ous.  ;    pressed. 


Apathy  common.  Con-    Preserved, 

sciousness  preserved  as   a 
rule. 


Frequent  and  often  fatal. 
(Gastric  and  intestinal 
chiefly.) 


Delirium     not     un- 
common. 


Of   rare   occurrence!  Rare  except  in  per- 

and  of  slight  con-     nicious    cases    and 
sequence.  in  malarial  hemo- 

globinuria. 


Fatality. 


Convalescence. 


Average    mortality    25    per    Non-fatal. 
cent. 


Rapid  and  without  sequels.    Rather  prompt  but 

with  arthralgic 
I  and  myalgic  se- 
I     quels. 


Rarely    fatal     if 
treated  properly. 

Slow,  succeeded  by 
-anemia,  and  is  apt 
to  recur. 


Immunity One    attack    confers     sub-    Doubtful  immunity    No  immunity. 

!     sequent  immunity. 


Response  to    Abortive  or  curative  treat- >  Symptomatic  treat- 
treatment,      j     ment  negative.  ;     ment  alleviates. 


Bloodcondition 


Incomplete  coagulation 

and  free  hemoglobin  in 
serum.  Red  cells  not 
greatly  altered.  _  White 
corpuscles  either  increased; 
or  decreased. 


Leukocytosis  com- 
mon. 

Decreased  leuko- 
cytes claimed  by 
some  observers. 


Satisfactory,  speci- 
fic (quinine)  treat- 
ment cures. 

Malaria  parasites 
and  pigment  pres- 
ent. Leucopenia 
with  a  relative 
increase  of  large 
mononuclear  leu- 
kocytes, the  rule. 


DENGUE  55 

« 

Treatment. — The  spread  of  the  disease  should  be  prevented  by- 
screening  the  apartments  of  infected  individuals  and  non-immunes 
by  ordinary  mosquito-netting.  Swamps  should  be  drained  and  cov- 
ered with  insecticides,  such  as  tobacco  and  petroleum,  and  the  popula- 
tion of  infected  regions  should  be  reduced  to  a  minimum. 

The  indications  are  to  keep  the  patient  quiet  in  bed  and  to  treat 
the  symptoms  as  they  arise.  Treatment  must  be  begun  at  once; 
there  is  no  time  to  be  lost.  The  fever  should  be  reduced  by  cold- 
water  baths  or  packs,  or  sponging,  or  ice-bag,  or  cold  enemata.  The 
coal-tar  derivative  antipyretics  should  not  be  used.  The  irritability 
of  the  stomach  permits  of  ingestion  of  food  of  only  the  most  bland 
character.  Mild  laxatives  such  as  castor  oil,  calomel,  and  citrate 
of  magnesia  may  be  employed  in  the  early  stages.  Quinine  should  be 
given  hypodermically.  The  gastric  irritation  may  be  relieved  by 
cracked  ice,  carbolic  acid,  gr.  J^  (0.016  gm.),  in  peppermint  water, 
milk  and  lime-water,  the  application  of  a  mustard  plaster  over  the 
epigastrium,  or — 

I^.     Hydrargyri  chlor.  mitis gr.  H2  0.005 

Morphinae  sulphat gr.  ^  0  o  •  003 

M.  S. — Every  two  hours  until  nausea  is  controlled. 

Sternberg  advises: 

I^.     Sodii  bicarb Sijss  10 . o-     gm. 

Hydrargyri  chloridi  corr.  . . .  gr.  3^^  o .  02  gm. 

Aquas  destillat Oij  950-0      c.c. 

M.  S. — Three  tablespoonfuls  every  hour. 

Stimulants  such  as  alcohol,  strychnine,  and  digitalis  should  be 
administered  to  support  the  patient,  and  the  hemorrhagic  tendency 
should  be  combated  by  Monsel's  solution,  acetate  of  lead,  adrenalin 
solution,  and  oil  of  turpentine.     Enteroclysis  is  also  advised. 

DENGUE 

Synon3nns. — Break-bone  fever;  dandy  fever.  The  word  dengue 
is  pronounced  dong-ga. 

Definition. — An  acute,  infectious,  epidemic,  febrile  disease,  con- 
sisting of  two  paroxysms  of  fever  with  an  intermission.  The  first 
paroxysm ,  is  characterized  by  high  fever,  distressing  pains  in  the 
joints  and  muscles,  and  a  peculiar  eruption;  the  second  paroxysm 
is  characterized  by  a  milder  fever,  an  eruption  of  different  character 


56  SCARLET   FEVER 

attended  with  intense  itching,  by  some  recurrence  of  the  joint  pains, 
and  by  debility. 

Cause. — The  specific  cause  is  still  undetermined;  but  it  is  believed 
to  be  transmitted  by  the  bite  of  a  mosquito — Culex  fatigans.  It  is  a 
tropical  and  subtropical  disease,  of  great  infectivity.  Incubation 
from  two  to  five  days. 

Sjnnptoms. — Onset  sudden — fever,  103°  to  io5°F.,  intense  head- 
ache, burning  pains  in  the  temples,  backache,  severe  aching  and 
swelling  of  the  joints  and  stiffness  of  muscles,  nausea,  vomiting,  con- 
stipation, and  the  appearance  of  a  rash,  resembling  scarlatina.  After 
some  hours  to  two  or  three  days  a  distinct  intermission  of  one  or  two 
days'  duration  takes  place. 

The  onset  of  the  second  paroxysm  is  also  sudden,  but  the  symptoms 
are  much  less  severe,  although  the  patient  is  greatly  debilitated;  it 
is  at  this  time  that  the  characteristic  eruption  appears,  being  either 
erythematous  or  roseolar  and  attended  with  intense  itching,  remain- 
ing for  about  two  days,  when  desquamation  occurs  and  convalescence 
is  established,  but  is  prolonged  by  the  great  debility  of  the  patient. 
Enlargement  of  the  lymph  glands  may  occur.  Average  duration  of 
the  disease  eight  days.     Relapses  are  common. 

Diagnosis. — The  history,  course,  paroxysmal  character,  and  varia- 
bility of  the  eruption  will  distinguish  it  from  acute  rheumatism, 
scarlet  fever,  and  measles  which  it  may  sometimes  resemble.  For 
differentiation  from  malaria  and  yellow  fever,  see  the  table  on  page  54. 

Prognosis. — Recovery  is  the  rule. 

Treatment. — There  is  no  special  treatment.  Isolation  and  pro- 
tection from  mosquitos  should  be  observed.  The  symptoms  should 
be  treated  on  general  principles.  Tincture  of  gelsemium  is  said  to  be 
of  great  service.  Laxatives,  antipyretics,  and  analgesics  are  often 
indicated,  and  during  convalescence  tonics  should  be  given.  The 
patient  must  be  kept  warm  and  his  diet  should  be  light  and  nutri- 
tious. 

SCARLET  FEVER 

« 

Synonym.— Scarlatina. 

Note. — Scarlatina  is  not  a  mild  form  of  scarlet  fever;  the  two 
terms  denote  exactly  the  same  disease. 

Definition. — An  acute,  self -limited,  contagious,  infectious  disease, 
characterized  by  high  temperature,  rapid  pulse,  a  diffused   scarlet 


SCARLET   FEVER  57 

eruption  terminating  with  desquamation,  inflammation  of  the  mouth 
and  throat,  a  tendency  to  nephritis,  and  frequently  more  or  less 
grave  nervoiis  phenomena. 

Cause. — It  is  due  to  a  special  microorganism  as  yet  undetected 
but  of  exceedingly  great  vitality.  It  retains  its  infecting  power  for 
at  least  one  year.  The  bearer  of  the  contagion  is  in  all  probability 
the  desquamated  epithelium  of  the  infected  persons,  the  disease 
being  particularly  communicable  during  desquamation.  The  poison 
is  disseminated  by  the  secretions  from  the  nose  and  throat,  the  scaly 
particles  in  the  air,  clothes  or  other  fomites,  food,  etc.  The  respira- 
tory tract  is  usually  the  route  of  infection  but  the  digestive  tract  may 
also  serve  to  carry  the  poison.  Children  are  most  likely  to  contract 
the  disease.     Second  attacks  are  very  uncommon  but  may  occur. 

Pathological  Anatomy. — There  are  no  characteristic  lesions.  The 
skin  is  the  seat  of  acute  inflammation  which  fades  away  in  death. 
The  liver,  spleen,  stomach,  kidneys,  heart,  and  muscles  undergo 
granular  changes.  The  throat  is  inflamed  and  ulceration  some- 
times occurs. 

Symptoms, — The  incubation  period  is  short,  varying  from  a  few 
hours  to  a  week,  after  which  the  affection  manifests  itself  in  one  of 
three  forms,  simple,  anginoid,  and  malignant. 

The  onset  of  the  disease  is  sudden,  being  marked  by  a  chill,  vomit- 
ing, or  convulsions,  followed  by  pain  in  the  throat,  high  fever,  io5°F., 
and  rapid  pulse,  no  to  140  beats  per  minute.  At  the  end  of  twenty- 
four  hours  a  bright  scarlet  rash  appears  on  the  neck  and  chest,  spread- 
ing over  the  entire  body  within  a  few  hours.  The  eruption  is  in 
appearance  like  a  boiled  lobster;  further,  it  is  not  raised,  and  dis- 
appears on  pressure.  Points  of  darker  hue  are  scattered  irregularly, 
but  there  is  no  intervening  healthy  skin,  the  rash  being  uniformly 
distributed.  The  eruption  may  vary  at  times;  occasionally  it  is 
scarcely  visible ;  in  some  instances  it  may  be  slightly  papular  or  vesicu- 
lar {scarlatina  miliaris) ;  and  in  malignant  cases  it  may  be  hemor 
rhagic  or  petechial.  As  soon  as  it  is  complete  it  begins  to  fade,  seldom 
lasting  more  than  five  days  or  a  week,  after  which  desquamation 
begins  and  occupies  from  two  to  six  weeks.  With  the  appearance 
of  the  rash  the  throat  symptoms  become  prominent.  Swallowiiig  is 
difficult,  there  are  pain  and  tenderness  in  the  throat  and  jaws,  the 
lymphatic  glands  are  swollen,  and  inspection  reveals  a  catarrhal 
inflammation  of  the  pharynx  and  tonsils.  A  punctiform  efflores- 
cence on  the  tonsils,  fauces,  and  pharyngeal  vault  may  be  observed 


58 


SCARLET  FEVER 


before  the  rash  appears.  The  tongue  is  at  first  furred  and  later  red 
with  prominent  papillae — the  ''strawberry  tongue."  Headache, 
restlessness,  and  delirium  may  be  present.  Breathing  is  rapid. 
The  appetite  is  lost  and  the  bowels  are  usually  constipated  but  diar- 
rhea is  not  uncommon.  The  urine  is  scanty,  high-colored,  and  often 
albuminous.  Leukocytosis  is  present.  The^  fever  declines  on  the 
fourth  or  fifth  day  by  lysis.  The  duration  of  simple  uncomplicated 
cases  is  from  three  to  fourteen  days.     Convalescence  is  slow. 


DAY  CF 
llskASE 

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L_ 

LJ 

1 — 

1 — 

1 — 1 

1 — 

l^ 

u 

1— J — 

1 — 1 

u 

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1 — LJ 

' — ' 

lJ 

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LJ 

y 

1 — 

Fig.  13. — Clinical  chart  of  scarlet  fever.     {From  Wilcox's  Fever  Nursing.) 


Anginoid  scarlet  fever  is  marked  by  a  predominance  of  the  throat 
symptoms.  There  is  high  fever  and  great  exhaustion.  Frequently 
the  enlarged  glands  suppurate. 

Malignant  scarlet  fever  is  characterized  by  convulsions,  delirium, 
muscular  twitchings,  high  temperature,  107°  to  iio°F.,  rapid,  feeble, 
and  irregular  pulse,  and  collapse.  The  eruption  is  of  purplish  color 
and  in  patches.     Death  may  occur  before  its  appearance. 

Complications. — The  principal  complications  are  acute  nephritis, 
adenitis,  arthritis,  and  otitis.  Convalescence  may  be  further  com- 
plicated by  chronic  sore  throat,  diphtheria,  ophthalmia,  diarrhea, 
otorrhea,  chorea,  endocarditis,  pericarditis,  pleurisy,  and  suppuration 
of  lymphatic  glands. 


SCARLET   PEVER  59 

Diagnosis. — The  distinctive  features  of  this  disease  are  the  high 
fever,  rapid  pulse,  sore  throat,  and  the  early  bright  scarlet  eruption 
with  its  subsequent  scaly  desquamation. 

Measles  differs  from  it  in  the  character  of  its  temperature,  pulse, 
and  eruption  and  is  marked  by  a  predominance  of  catarrhal  symptoms. 

Diphtheria  resembles  the  anginoid  variety  but  may  be  distinguished 
by  the  absence  of  the  eruption  and  strawberry  tongue  and  by  the 
presence  of  the  false  membrane  and  the  Klebs-Loeffler  bacillus. 

Acute  tonsillitis  may  be  distinguished  by  the  absence  of  the  charac- 
teristic temperature,  pulse,  eruption,  strawberry  tongue,  and  the 
tendency  toward  nephritis. 

Meningitis  and  malignant  scarlet  fever  are  somewhat  similar,  but 
the  history,  mode  of  onset,  pulse,  and  eruption  will  serve  to  make  a 
diagnosis. 

Erythema  scarlatinoides  has  several  points  in  common  with  scarla- 
tina, but  may  be  distinguished  from  it  by  its  non-contagious  nature, 
the  mild  constitutional  disturbance,  the  irregular  distribution  of  the 
rash  (the  face  being  usually  free),  desquamation  on  the  fourth  day, 
the  absence  of  the  strawberry  tongue,  and  the  tendency  toward 
recurrence. 

Drug  rashes  show  an  eruption,  but  present  no  fever  or  other 
symptom.  Belladonna,  quinine,  potassium  iodide,  chloral,  and 
acetanilide  are  the  chief  drugs  producing  a  rash. 

Prognosis. — The  mortality  varies  from  5  to  10  per  cent,  in  mild 
epidemics,  to  20  to  30  per  cent,  in  severe  epidemics.  The  occurrence 
of  complications  adds  to  the  gravity  and  uncertainty  of  the  case. 

Treatment. — Isolation,  rest  in  bed,  liquid  diet,  and  careful  disinfec- 
tion of  all  the  sick-room  articles  is  highly  essential.  The  patient 
requires,  and  should  be  given,  plenty  of  cold  water  to  drink.  The 
fever  should  be  controlled  by  the  cold  bath  (90°F.,  and  gradually 
reduced),  douche,  pack,  or  cool  sponging.  An  ice-bag  should  be 
applied  to  the  head.  Drugs,  such  as  citrate  of  potassium,  solution 
of  ammonium  acetate,  spirit  of  nitrous  ether,  and  tincture  of  aconite, 
alone  or  combined,  may  also  be  employed.  The  bowels  should  be 
kept  regular  by  the  administration  of  very  small  doses  of  calomel, 
soda,  and  ipecac,  combined.  Failing  circulation  will  indicate  the 
use  of  digitalis,  strychnine,  belladonna,  nitroglycerin,  alcohol,  and 
the  hot  bath  or  pack.    Rotch  gives  a  useful  dosage  table  (see  page  60) . 

It  should  be  remembered  that  scarlet  fever  is  infectious  from  the 
first  day,  but  how  long  the  possibility  of  infection  may  last  no  one 


6o 


SCARLET   FEVER 


Age 

Tincture  of 
digitahs. 
Minim 

Strychnine. 
Grain 

I  per  cent,  solution 

nitroglycerin. 

Minim 

Atropine. 
Grain 

3  months 

Ko-M 

J'^ooo-Hooo 

M5-3^o 

Hooo-Ksoo 

6  months 

Mo-M 

Hboo-Hoo 

H5-M5 

Hsoo^Hooo 

9  months 

K-i  , 

Moo-Hoo 

M5-K0 

Ksoo-Mso 

12  months 

K-i>^ 

M00-M50 

H5-K 

Mooo-Koo 

2  years 

3-^-2 

Hoo^Hso 

Ms-K 

M50-H50 

3  years 

H-3 

Hoo-Hoo 

Mo-J-^ 

Hoo-J-^00 

4-10  years 

1-5 

Moo-Ho 

3-^-% 

J'iso-Mso 

10-12  years 

3-8 

Koo-J^o 

M-i 

/'200~MoO 

can  say.  The  child  should  be  isolated  for  not  less  than  six  weeks  from 
the  appearance  of  the  rash,  and  should  not  then  be  allowed  to  mingle 
with  other  people  unless  apparently  quite  well  and  free  from  all 
discharges  from  nose,  throat,  and  ears.  Toys,  fomites,  etc.,  should 
be  burned. 

With  the  appearance  of  the  eruption  the  body  should  be  anointed 
with  cold  cream,  cocoa-butter,  or  the  following: 


I^.     Eucalyptol f  5  J 

Petrolat 5j 

M.  S. — Apply  locally  as  directed. 


4  CO. 

32  gm. 


In  anginoid  scarlet  fever  the  following  formula  will  be  found 
valuable : 

I^.     Tincturae  ferri  chlorid f  5ij  8  c.c. 

Glycerin f §j  30  c.c. 

Aquas q.  s.  ad  f  5ij        ad     60  c.c. 

M.  S. — One-half  to  one  teaspoonful  every  two  hours,  undiluted, 
according  to  the  age. 


Externally,  in  these  cases,  ice  and  cold  compresses  should  be 
employed  unless  they  produce  discomfort,  when  heat  should  be 
substituted.  Pellets  of  ice  allowed  to  dissolve  in  the  mouth  often 
produce  considerable  relief.  Dobell's  solution  should  be  used  to 
spray  the  nasal  fossae  and  pharynx  every  hour. 

I^.     Acid,  carbolici f  5jss  6  c.c. 

Sodii  biboratis, 

Sodii  bicarb aa   5ij  8  gm. 

Glycerini f  §ij  60  c.c. 

Aquae q.  s.  ad  Oij  ad     950  c.c. 

M.  S.— Dobell's  solution. 


SCARLET   FEVER  6l 

The  following  gargle  may  also  be  employed  with  benefit: 

I^.     Thymol gr.  iv  o. 26  gm. 

Glycerin f  5j  30  c.c. 

Aq.  dest f 5j  30  c.c. 

M.  S. — A  throat  wash,  dilute  if  necessary. 

Peroxide  of  hydrogen,  full  strength  or  diluted,  may  also  be  used 
to  antisepticize  the  mouth  and  throat. 

In  malignant  scarlet  fever,  stimulation  is  the  most  important  fea- 
ture of  the  treatment.  Whiskey,  brandy,  iron,  quinine,  and  strych- 
nine, should  be  administered  to  their  physiological  limit. 

Convulsions,  restlessness,  tremors,  and  other  nervous  phenomena 
are  best  controlled  by  hydrotherapeutic  measures,  but  the  use  of 
bromides  and  chloral  may  be  necessary  in  severe  cases. 

Serum  treatment,  using  the  antistreptococcic  serum,  has  been 
employed  with  the  view  of  preventing  complications. 

Acute  nephritis  is  a  common  occurrence  in  scarlet  fever  particularly 
after  desquamation,  in  the  second,  third,  and  fourth  weeks.  The 
urine  should  be  examined  daily  in  order  to  detect  this  complica- 
tion as  early  as  possible.  Milk  diet,  digitalis,  and  protection  of  the 
patient  from  drafts  are  to  a  large  extent  preventive.  With  the  devel- 
opment of  nephritis  the  following  prescriptions  may  be  employed: 

I^.     Potassii  acetat 5ij  8  gm. 

Spt.  setheris  nitrosi §ss  15  c.c. 

Aquae ! q.  s.  ad   §ij         ad     60  c.c. 

M.  S. — Teaspoonful  every  two  hours,  well  diluted. 

Or— 

I^.     Hydrargyri  chlor.  mitis, 
Pulv.  scillse, 

Pulv.  digital aa  gr.  3'^  to  14,     0.016   to   0.032  gm 

M.  Ft.  pil.  No.  j. 
S. — One  such  pill  every  three  or  four  days. 

Or— 

I^.     Potassii  acetatis, 

Potassii  bicarbonatis,    • 

Potassii  citratis aa    5ij  8  c.c. 

Infusi  tritici  repentis  q.  s.  ad   Bviij  240  c.c. 

M.  S. — One  teaspoonful  every  three  or  four  hours  (for  a  child 
five  years  old). 

Saline  purgatives,  dry  cupping  over  the  loins,  warm  baths,  hot 


62  MEASLES 

packs,  vapor  baths,  enteroclysis,  and  pilocarpine  will  be  indicated 
to  relieve  the  system  of  the  accumulated  poisons.  Convulsions  will 
require  the  use  of  chloral,  bromides,  sodium  benzoate,  and  chloroform 
in  addition. 

The  scarlatinal  arthritis  will  be  benefited  by  the  alternate  adminis- 
tration of  iron  and  the  following  mixture: 

'Sf,.     Ammonii  salicylat 5ij  8  gm. 

EHx.  simplicis •.  . .    §ss  15  c.c. 

Syr.  simplicis §  j  30  c.c. 

Tinct.  card,  comp gss  15  c.c. 

M.  S. — Teaspoonful,  diluted,  four  times  daily 

In  otitis,  the  application  of  a  hot  water  bottle  or  syringing  the  canal 
with  hot  water  will  serve  to  lessen  the  pain,  but  should  the  tympanic 
membrane  bulge  it  should  be  punctured  to  "allow  evacuation  of  any 
confined  pus. 

Quarantine. — A  child  who  has  been  exposed  to  scarlet  fever  may 
safely  return  to  school  ten  days  after  the  date  of  such  (last)  exposure. 
A  child  v/ho  has  had  an  attack  of  scarlet  fever  should  not  be  allowed 
to  return  to  school  till  all  desquamation,  sore  throat,  discharge  from 
nose  and  ears,  and  albuminuria  have  disappeared;  and  in  no  case  in 
less  than  six  weeks. 

MEASLES 

Synonyms. — Morbilli;  rubeola. 

Definition. — An  acute  epidemic  and  contagious  disease;  character- 
ized by  catarrhal  symptoms,  referable  to  the  naso-broncho-pulmonary 
mucous  membrane,  fever,  and  a  crimson  mottled,  papular  eruption 
which  terminates  by  branny  desquamation. 

Cause. — The  cause  is  an  unknown  microorganism  apparently 
associated  with  the  nasal  and  bronchial  secretions.  It  is  often 
communicated  by  sneezing,  and  may  be  transmitted  through  a 
third  party,  also  through  clothes  and  other  fomites.  Children  are 
especially  predisposed  to  it,  but  adults  may  be  attacked.  It  usually 
occurs  in  epidemic,  but  sporadic  cases  may  be  observed.  One  attack 
usually  confers  immunity,  but  second  attacks  are  not  very  uncommon. 

Pathological  Anatomy. — There  are  no  characteristic  structural 
changes.  Catarrhal  inflammation  of  the  entire  respiratory  tract 
is  almost  a  constant  accompaniment.  Gastrointestinal  catarrh 
may  also  be  present. 


MEASLES 


/ 


63 


r^T  J 


Symptoms. — After  an  incubation  period  of  from  ten  to  fourteen 
days  the  disease  is  manifested  by  a  chill  or  chilliness,  fever  ranging 
from  101°  to  io2°F.,  muscular  soreness,  headache,  and  intense 
nasal,  pharyngeal,  and  laryngeal  catarrh.  There  are  present  also 
intolerance  to  light,  redness  and  watering  of  the  eyes,  sneezing,  and 
coughing;  On  the  second  day  the  fever  remits  to  rise  again  on  the 
fourth  day,  when  an  eruption  of  small,  dark  red,  velvety  papules 
arranged  in  crescentic  groups,  appears  on  the  face  and  soon  spreads 
over  the  entire  body.     The  catarrhal  symptoms  still  persist.     The 


DAY  OF 
DISEASE 

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Fig.  14.- 


-Clinical  chart  of  measles  showing  defervescence  by  lysis  beginning  when 
the  eruption  is  fully  developed.     {From  Wilcox's  Fever  Nursing.) 


eruption  is  attended  by  itching  and  more  or  less  burning,  and  about 
the  ninth  day  begins  to  fade  and  disappear  entirely  by  bran-like 
desquamation.     All  the  symptoms  then  gradually  ameliorate. 

Koplik  has  described  a  peculiar  eruption  consisting  of  small  irregu- 
lar spots  of  a  bright  red  color,  each  having  a  bluish-white  center, 
which  appear  on  the  mucous  membrane  of  the  lips  and  cheeks  on  the 
first  day  of  invasion  and  which  he  believes  to  be  pathognomonic. 
They  fade  away  with  the  appearance  of  the  dermal  eruption. 

Black  measles,  hemorrhagic  measles,  or  malignant  measles  is  that 
variety  in  which  the  eruption  is  hemorrhagic  in  character  and  there 


64  .  MEASLES 

is  profound  prostration.  It  is  encountered  in  camps,  jails,  and  other 
places  in  which  the  hygiene  is  very  poor. 

Complications. — The  most  common  complications  are  catarrhal 
pneumonia  and  gastroenteritis.  As  sequels  may  be  mentioned 
tonsillitis,  tuberculosis,   ophthalmia,   and  cancrum  oris. 

Diagnosis. — The  characteristic  features  of  measles  are  its  gradual 
onset,  often  with  drowsiness,  chilliness,  nasal  catarrh,  watery  eyes, 
fever  which  declines  on  the  second  day  to  rise  on  the  fourth,  the 
appearance  of  a  crimson  papular  eruption  on  the  fourth  day  preceded 
by  Koplik's  spots  on  the  first  day,  and  the  bran-like  desquamation. 
There  is  no  leukocyi:osis  in  uncomplicated  cases. 

Scarlet  fever  may  be  distinguished  by  the  absence  of  Koplik's 
spots  and  the  difference  in  the  date  and  character  of  the  eruption, 
pulse,  temperature,  and  symptoms. 

German  measles  or  roetheln  may  be  diagnosed  by  the  difference  in 
the  eruptions  and  the  absence  of  constitutional  manifestations. 

Pityriasis  rosea  resembles  measles  somewhat,  but  its  rose-colored 
erythemato-squamous  and  papular  patches  are  confined  to  the  trunk 
and  there  are  no  constitutional  disturbances  as  a  rule.  It  is  of  longer 
duration. 

Prognosis. — Nearly  all  uncomplicated  cases  recover.  Lung  com- 
plications are  always  of  serious  import.  In  black  measles,  the  major- 
ity succumb. 

Treatment. — Isolation,  rest  in  bed,  and  protection  from  drafts  and 
from  bright  light  are  necessary  from  the  onset  of  the  disease.  It  is 
often  desirable  to  give  a  diaphoretic  mixture,  such  as  the  following : 

I^.     Potassii  nitratis 5j  4-0  gm. 

Liquoris  ammonii  acetatis  . .    §ij  60.0  c.c. 

Vini  ipecacuanhae TTlxxxvj  2  .  5  c.c. 

■     Syrupi  limonis 5vj  24 .  o  c.c. 

Aquse q.  s,  ad   5vj  180.0  c.c. 

M.  S. — One  to  two  tablespoonfuls  every  four  or  five  hours. 

The  bowels  should  be  kept  regular  by  means  of  some  mild  laxative. 
The  diet  should  be  semisolid.  Mild  cases  require  no  medicines. 
Cool  sponging  or  the  following  will  reduce  the  temperature  when  it 
becomes  alarmingly  high: 

I^.     Tinct,  aconiti TTtij  to  iv  o .  12  to  o .  24  c.c. 

Spt.  aetheris  nitrosi TTlx  to  xv  0.6    to  i  .0    c.c. 

Liq.  potas.  citrat q.  s.  ad  f  5j  4-0  c.c. 

M.  S. — Every  two  hours. 


RUBELLA  65 

Daily  inunctions  of  cold  cream,  cocoa-butter,  eucalyptol  in  petro- 
latum, and  similar  oily  substances  will  serve  to  relieve  the  itching 
of  the  eruption.  Camphorated  oil  rubbed  on  the  chest  and  applied 
to  the  nose  and  neck  aids  in  lessening  the  catarrhal  symptoms. 

During  convalescence  iron,  strychnine,  quinine,  cod-liver  oil, 
syrup  of  the  iodide  of  iron,  and  similar  tonics  should  be  advised. 

Black  measles  requires  constant  stimulation  in  addition  to  other 
measures.     The  various  symptoms  should  be  treated  as  they  arise. 

Quarantine. — A  child  who  has  been  exposed  to  infection  by  measles 
should  not  be  allowed  to  return  to  school  till  sixteen  days  have  elapsed 
since  such  (last)  exposure.  And  a  child  who  has  had  measles  should 
not  be  allowed  to  return  to  school  till  at  least  one  month  after  the 
onset  of  the  symptoms,  and  only  then  provided  no  discharges  are 
present,  and  in  the  absence  of  sequelae. 

[      RUBELLA 

Synonyms. — Roe theln;  epidemic  roseola;  German  measles;  French 
measles;  false  measles. 

Definition. — An  acute,  self -limited,  contagious  disease;  character- 
ized by  mild  fever,  suffused  eyes,  cough,  sore  throat,  enlargement  of 
the  lymphatic  glands  of  the  neck,  and  a  rose-colored  eruption,  in 
patches  of  irregular  size  and  shape,  appearing  on  the  first  day. 

Many  so-called  second  attacks  of  measles  and  scarlet  fever  are 
attacks  of  rubella  (Tyson). 

Cause. — The  disease  is  due  to  some  special  microorganism  as  yet 
undiscovered.  It  may  be  epidemic  or  sporadic.  The  contagion 
is  disseminated  by  clothes  and  other  fomites.  Childhood  is  a  pre- 
disposing factor.     One  attack  usually  confers  immunity. 

Symptoms. — The  onset  is  sudden  with  mild  fever,  suffused  eyes, 
little  or  no  coryza,  sore  throat,  enlargement  of  the  cervical  glands, 
and  an  eruption  of  rose-colored,  pin-head-sized  spots  which  appear 
any  time  from  the  first  to  the  fourth  day.  All  the  symptoms  dis- 
appear within  a  week  by  lysis. 

Prognosis. — Recovery  is  almost  constant. 

Treatment. — There  is  no  special  treatment ;  the  measures  indicated 
under  measles  are  applicable  to  this  disease. 

Quarantine. — A  child  who  has  been  exposed  to  infection  by  this 
disease  should  not  be  allowed  to  return  to  school  until  twenty  days 
have  elapsed  since  such  (last)  exposure.  And  a  child  who  has  had 
5 


66  SMALL-POX 

the  disease  should  not  be  allowed  to  return  to  school  until  one  month 
has  elapsed  since  the  beginning  of  the  attack. 

SMALL-POX 

Synonjmi. — Variola. 

Definition. — ^An  acute  epidemic  and  contagious  disease;  character-, 
ized  by  severe  lumbar  pains,  vomiting,  and  an  initial  fever,  lasting 
from  three  to  four  days,  followed  by  an  eruption  which  passes 
through  the  stages  of  macule,  papule,  vesicle,  and  pustule;  the 
development  of  the  pustule  being  accompanied  by  a  secondary  fever 
during  the  presence  of  which  grave  complications  are  prone  to  occur. 

Causes. — Probably  an  intracellular  parasitic  protozoon,  the  Cyto- 
ryctes  variolcB;  it  maintains  its  contagious  vitality  for  a  long  period. 
There  is  no  period,  from  the  initial  fever  to  the  final  desquamation, 
when  the  disease  is  not  contagious,  although  the  stage  of  suppiuration 
is  the  most  virulent.  One  attack,  as  a  rule,  protects  from  a  second. 
Vaccination  has  a  positive  protective  influence  from  the  disease,  an 
extensive  observation  having  fully  proven  that  in  proportion  to  the 
efficiency  of  vaccination  is  the  rarity  and  mildness  of  variola. 

Pathological  Anatomy. — The  eruption  (with  its  four  stages  of 
macule,  papule,  vesicle,  and  pustule)  is  the  only  distinctive  patho- 
logical lesion.  The  depression  in  the  center  of  the  pustule  corresponds 
to  the  area  of  primary  necrosis.  A  granular  and  fatty  degeneration 
occurs  in  the  liver,  spleen,  kidneys,  and  heart.  The  pustules  are 
found  in  the  larynx,  trachea,  bronchial  tubes,  and  on  the  pleura. 

Varieties. — Three  forms  of  the  disease  are  described: 

1.  Variola  vera,  or  simple  small-pox,  which  may  be  {a)  discrete  or 
(6)  confluent. 

2.  Variola  hcsmorrhagica,  hemorrhagic  or  malignant  smallpox. 

3.  Variola  benigna,  or  varioloid,  or  small-pox  modified  by  vaccina- 
tion. 

Symptoms. — The  manifestations  of  small-pox  are  preceded  by  an 
incubation  period  which  varies  from  seven  to  fifteen  days. 

In  the  discrete  form  the  onset  is  sudden  with  a  violent  chill,  vomiting, 
intense  headache,  and  agonizing  pains  in  the  back  shooting  down 
the  limbs.  In  children  the  chill  may  be  replaced  by  one  or  more  con- 
vulsions. The  temperature  rises,  reaching  103°  to  io4°F.  within  a 
short  time. 

The  pulse  is  full,  strong,  and  rapid,  ranging  from  100  to  130. 
The  face  is  red  and  the  eyes  are  injected.     Intense  headache,  sleep- 


SMALL-POX 


67 


lessness,  delirium,  and  convulsions  may  and  often  are  present.  Pros- 
tration is  profound.  On  the  third  day  the  characteristic  eruption 
appears  first  on  the  forehead  and  lips,  consisting  of  coarse  red  spots. 
It  may  be  preceded  by  a  diffuse  scarlatinous  or  measly  rash  (some- 
times petechial  in  character)  most  marked  on  the  inner  surface  of  the 
arms  and  thighs. 

The  true  eruption  becomes  distinctly  papular  within  twenty-four 
hours  and  the  lesions  acquire  shot-like  hardness.  With  the  appear- 
ance of  the  eruption  all  the  symptoms  abate,  the  temperature  falls 


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Fig.  is. — Clinical  chart  of  small-pox  showing  fall  of  temperature  upon  the  appearance 
of  the  eruption  and  its  rise  upon  the  incidence  of  the  stage  of  pustulation.  {From 
Wilcox's  Fever  Nursing.) 

several  degrees,  and  the  patient  feels  quite  comfortable.  On  the 
sixth  day  of  the  disease  the  papules  become  converted  into  umbil- 
icated  and  loculated  vesicles,  and  on  the  eighth  or  ninth  day  these 
lose  their  umbilication  and  become  mature  pustules,  each  surrounded 
with  a  broad  red  band.  The  temperature  again  rises  and  the  symp- 
toms reappear  at  this  period.  There  is  marked  edema  of  the  skin 
between  the  lesions,  causing  swelling  of  the  surface  and  rendering 
the  features  unrecognizable.  The  tension  of  the  pustules  induces 
localized  pains  particularly  in  the  face;  the  eyelids  become  swollen 
and  closed.     On  the  tenth  or  eleventh  day  the  pustules  begin  to  dry 


6S  SMALL-POX 

up  and  are  converted  into  scabs  or  crusts  by  the  fourteenth  day. 
These  emit  a  pecuHar,  offensive  odor  and  fall  off  from  the  seventeenth 
to  the  twenty-first  day,  leaving  a  red,  glistening  depression  or  pit 
which  later  changes  into  a  white  cicatrix.  The  secondary  fever  lasts 
about  three  or  four  days,  in  favorable  cases  terminating  by  lysis. 

Confluent  small-pox  is  characterized  by  early  appearance  of  the 
eruption,  coalescence  of  the  pustules  (chiefly  on  the  face),  marked 
prostration,  delirium,  stupor,  high  and  irregular  secondary  fever, 
swelHng  of  the  surface,  and  distortion  of  the  features.  Convales- 
cence is  tedious  and  disfiguring  sequels  are  common  in  most  favorable 
cases. 

Malignant  or  hemorrhagic  small-pox  consists  in  the  appearance  of 
widely  distributed  purpuric  spots  before  the  true  eruption  or  in  the 
occurrence  of  hemorrhages  into  the  mature  pustules.  Bleeding  from 
the  mucous  membranes  is  common.  The  onset  is  usually  sudden  and 
violent;  all  the  symptoms  are  intensified.  This  variety  is  also  known 
as  black  small-pox  and  is  nearly  always  fatal. 

Varioloid  is  that  modified  variety  of  small-pox  which  occurs  in 
vaccinated  individuals  or  those  who  have  previously  been  attacked. 
Its  course  is  shorter  and  milder  than  other  forms,  the  eruption  appears 
later,  there  is  no  secondary  fever,  the  pocks  are  smaller,  and  there  is 
little  or  no  pitting. 

Complications. — During  the  course  of  the  secondary  fever  there  is 
a  great  tendency  toward  pleurisy,  bronchopneumonia,  laryngitis, 
and  dysentery.  During  convalescence,  boils,  abscesses,  ulcerative 
eye-diseases,  otitis,  neuritis,  and  arthritis  are  prone  to  develop. 

Diagnosis. — The  characteristic  features  of  this  disease  are  the 
remittent  type  of  fever,  sudden  onset  with  chill,  vomiting,  and 
excruciating  pains  in  the  back  and  legs,  and  the  appearance  of  a 
papular  eruption  on  the  third  day  which  later  becomes  vesicular  and 
then  pustular. 

In  measles  the  initial  symptoms  are  less  severe,  the  pain  in  the  back 
is  never  so  excruciating;  the  coryza,  photophobia,  cough,  and  Kop- 
lik's  spots  are  all  very  characteristic  of  measles.  Further,  the  fever 
does  not  subside  after  the  eruption  appears. 

Varicella  ma^?-  resemble  variola,  but  the  constitutional  symptoms 
are  less  severe  and  the  eruption  which  is  essentially  vesicular  appears 
on  the  first  day  coming  out  in  crops.  The  lesions  dry  up  within  two 
or  three  days. 

Syphilis  may  be  distinguished  by  its  history,  the  polymorphous 


SMALL-POX  69 

character  of  the  eruption  and  its  symmetrical  distribution,  the 
Wassermann  reaction,  the  adenopathy,  the  alopecia,  and  the  mild 
constitutional  symptoms. 

Scabies  is  attended  by  papules  and  pustules  and  may  simulate  the 
eruption  in  mild  cases  of  variola.  The  presence  of  the  itch-mite 
between  the  fingers  will  serve  to  make  the  diagnosis. 

Prognosis. — This  depends  upon  the  variety  of  the  attack,  the 
age  of  the  patient,  and  the  presence  or  absence  of  vaccination.  In 
unprotected  persons  the  death  rate  is  from  25  to  35  per  cent.;  in 
the  malignant  form  all,  or  almost  all,  perish.  In  those  under  five 
years  of  age  and  over  forty  years  the  mortality  is  50  per  cent.,  and 
in  unvaccinated  individuals  it  ranges  from  20  to  60  per  cent.  The 
mortality  of  varioloid  is  a  little  over  i  per  cent. 

Treatment. — Compulsory  vaccination,  properly  carried  out,  would 
prevent,  if  not  entirely  exterminate,  small-pox.  As  in  other  conta- 
gious diseases,  isolation,  ventilation,  cleanliness,  and  disinfection  are 
imperative.  The  patient  should  be  confined  to  bed  in  a  darkened 
room,  the  average  temperature  of  which  is  65°F.  The  diet  should 
consist  of  milk,  eggs,  animal  broths,  oysters,  beef-juice,  and  similar 
foods  administered  every  three  hours  from  the  onset.  If  vaccination 
has  not  already  been  performed,  the  patient  should  be  immediately 
vaccinated,  as  it  may  possibly  modify  the  attack.  The  initial  fever 
and  the  accompanying  symptoms  may  be  relieved  by  phenacetin, 
gr.  X  (0.65  gm.),  antifebrin,  gr.  v  (0.32  gm.),  acetanilide,  gr.  v  to  x 
(0.32  to  0.65  gm.),  or  antipyrine,  gr.  x  (0.65  gm.),  repeated  as  the 
occasion  requires  it,  avoiding  depression.  Headache  may  be  con- 
trolled by  the  application  of  sinapisms  to  the  neck  and  an  ice-bag  to 
the  head.  Sleeplessness,  restlessness,  and  delirium  indicate  the 
employment  of  the  bromides,  trional,  chloral,  or  opium.  The  irrita- 
bility of  the  stomach  may  be  overcome  by  ice  pellets  allowed  to  dis- 
solve in  the  mouth  and  the  administration  of  dilute  hydrocyanic 
acid  (Ulij).  Excessive  diarrhea  may  be  controlled  by  camphorated 
tincture  of  opium,  bismuth  subnitrate,  or  lead  acetate  with  opium. 
With  the  onset  of  the  secondary  fever,  quinine,  tincture  of  the  chloride 
of  iron,  and  brandy  should  be  administered  in  full  doses.  Tincture  of 
aconite  is  also  useful.  Hydrotherapy  should  be  used  to  combat  high 
temperature.  The  mouth  and  nasopharynx  should  be  cleansed  with 
Dobell's  solution  (for  composition,  see  page  60)  and  all  crusts  should 
be  carefully  removed,  and  boric  acid  lotion  should  be  employed  to 
irrigate  the  conjunctival  sac. 


70  VACCINATION 

To  prevent  pitting  the  patient  should  be  kept  in  the  dark  and  covered 
with  some  unctuous  material  or  with  cold  wet  dressings  of  bichloride 
of  mercury  (i  :  5000  to  i  :  1000)  or  carbolic  acid  (10  gr.  to  the 
ounce).  Hot-water  dressings  may  be  more  gratefully  received. 
Painting  of  the  pustules  with  ichthyol,  5  to  20  per  cent.,  is  also  recom- 
mended. Schamberg  advises  painting  with  iodine.  A  lotion  con- 
sisting of  picric  acid  (30  gr.),  alcohol  (3^  ounce),  and  water  (6>^ 
ounces)  has  also  been  recommended.  Collodion  is  sometimes  em- 
ployed. When  wet  dressings  are  undesirable  eucalyptol  in  petrola- 
tum (5j  to  §j)  or  carbolic  acid  and  lanolin  (gr.  x  to  5j)  may  be 
applied. 

Among  the  special  forms  of  treatment  may  be  mentioned  the  Fin- 
sen  red-light  treatment,  the  internal  antiseptic  treatment,  and  anti- 
septic baths. 

Quarantine. — A  child  who  has  been  exposed  to  small-pox  should 
not  be  allowed  to  return  to  school  till  sixteen  days  since  the  date  of 
such  (last)  exposure.  And  a  child  who  has  suffered  from  the  disease 
should  not  be  allowed  to  return  to  school  till  one  week  has  elapsed 
since  the  disappearance  of  the  last  scab,  and  not  till  six  weeks  since 
the  first  appearance  of  symptoms. 

.VACCINATION 

Synonyms. — Vaccinia;  cow-pox. 

Definition.— The  reaction  which  follows  inoculation  with  the 
vaccine  virus  or  virus  of  cow-pox.  It  furnishes  almost  complete 
immunity  against  small-pox.  It  should  be  performed  in  infancy, 
at  puberty,  and  whenever  small-pox  is  prevalent. 

Nature  of  Vaccinia. — There  are  two  views:  (i)  that  it  is  small-pox 
modified  by  transmission  through  the  cow;  (2)  that  it  is  a  separate 
disease,  distinct  from  small-pox.  The  question  is  not  settled,  but 
the  former  view  is  probably  correct. 

Etiology. — Unknown,  but  probably  a  protozoon — the  Cytoryctes 
vaccinice. 

Lymph  in  Use. — Animal  lymph,  a  lymph  from  the  cow,  is  now 
almost  universally  used,  but  humanized  lymph  can  also  be  used. 

Value  of  Vaccination. — There  can  be  no  doubt  that  compulsory 
vaccination  would  prevent,  if  not  actually  exterminate,  small-pox. 
"The  German  army  since  1874,  the  date  of  the  stringent  laws,  has 
enjoyed  practical  immunity — not  a_single  death  from    small-pox 


VACCINATION  7 1 

(to  the  date  of  the  last  report,  1902),  except  an  isolated  case  under 
peculiar  circumstances  in  1884-85"  (Osier). 

Operation. — The  area  selected  should  be  carefully  cleansed  with 
soap  and  water  and  alcohol.  The  skin  should  be  scratched  and 
cross-scratched  with  an  aseptic  needle  or  special  scarifier,  being  care- 
ful not  to  produce  bleeding  but  instead  merely  oozing  of  pinkish 
serum.  The  virus  is  then  rubbed  in  by  means  of  the  needle  or  scari- 
fier making  additional  scratches. 

Symptoms. — Successful  vaccination  will  be  manifested  on  the 
third  day  by  a  papule  which  becomes  a  vesicle  on  the  sixth  day  and  a 
pustule  on  the  eighth  day  surrounded  by  a  reddish  areola.  The 
adjacent  tissues  are  red  and  infiltrated.  Tenderness  and  itching 
are  also  present.  The  areola  begins  to  fade  on  the  tenth  day,  and 
the  pustule  is  converted  into  a  mahogany-brown  crust  by  the  four- 
teenth day  becoming  detached  about  the  twenty-third  day.  The 
resultant  scar  is  circular,  depressed,  foveated,  radiated,  and  paler 
than  the  surrounding  integument.  In  some  cases  slight  fever, 
malaise,  restlessness,  glandular  enlargement,  and  other  constitutional 
symptoms  are  present. 

Complications. — Infection  may  occur  resulting  in  abscess,  erysipe- 
las, or  tetanus.  Occasionally  the  eruption  may  be  generalized. 
Sometimes  it  is  followed  by  various  eruptions  resembling  roseola, 
rubeola,  urticaria,  eczema,  erythema  multiforme,  and  similar  affec- 
tions. 

Syphilis  and  tetanus  have  been  transmitted  by  vaccination;  that 
tuberculosis  and  leprosy  have  been  so  transmitted  has  been  claimed 
but  never  proved.  Hence  the  most  scrupulous  "^  care  should  be 
observed  in  the  preparation  of  the  animal  virus  and  all  antiseptic 
and  aseptic  precautions  should  be  taken  in  performing  vaccination. 

Tyson  truly  says:  "It  is  exceedingly  important  that  the  physician 
should  have  at  hand  the  data  of  discriminating  between  the  ulcer  of 
vaccinosyphilis  and  of  vaccination  and  between  secondary  vaccino- 
syphilis,  and  vaccination  rashes,  and  hereditary  syphilis  occurring 
about  the  time  of  vaccination.  Such  data  are  found  in  the  following 
tables:" 


72 


VACCINATION 


Vaccinosyphilis  or  vaccino-chancre 


Vaccination  ulcers 


Chancre  developed  on  the  site  of  usually]  Ulceration  affects  all    the  punctures,  as  a 

one    or    two    only    of    the    vaccination;     rule. 

punctures.    _  :  _  _ 

Inflammation  is  slight Inflammation  and  ulceration  severe. 

Loss  of  substance  superficial  only Ulcer  deeply  excavated. 

Suppuration   scanty    or    absent,    scabs,    or    Much  suppuration. 

crusts.  '  _ 

Border    of    chancre    smooth,    slightly  ele-    Margin     of    ulcer    irregular,    as    in    "soft 

vated,  gradually  merging  into  floor.  i       chancre." 

Surface  of  floor  smooth |  Floor  of  ulcer  uneven,  suppurating. 

Induration  "parchment-like,"  and  specific,!  Induration  inflammatory  only. 

not  merely  inflammatory.  ! 

Inflammatory  areola  very  slight Areola  inflammatory  and  erysipelatous. 

Gland    swelling   constant,    indolent    (syph-|  Gland    swelling   often   absent;   if   present, 

ilitic")  bubo.  j       merely  inflammatory. 

Complications  rare i  Complications — sloughing,  erysipelas,  etc. 

!       — often  present. 
Chancre   never   developed   before   the   fif-l  Ulceration    is    present    twelve    to_  fifteen 

teenth    day    after    vaccination;    usually'       days     after    vaccination    and    is    fully 

not   until  a^^ter  three  to   five  weeks;   it        developed  the    twelfth    day  after    vac- 
,  is  still  in  its  earlier  stage  twenty  daysi       cination. 

after  vaccination.  I 


Secondary     syphilitic     eruption 
vaccinosyphilis 


Vaccination  rashes. 


due  to'  (Including  roseola  vaccinalis,  miliaria  vac- 
cinalis,  vaccinia  bullosa,  vaccinia  haem- 
orrhagica;  also  accidental  eruptions — 
rubeola,  scarlatina,  lichen,  urticaria,  etc.) 


Appears,  at  the  earliest,  nine  or  ten  weeks 
after  vaccination. 

Requires,  in  every  case,  the  preexistence 
of  a  specific  ulcer  (chancre)  at  the  site 
of  vaccination. 

Exhibits  the  character  of  a  true  specific 
eruption. 

Fever  often  slight. . . ._ 

Lasts  for  a  long  time.  Usually  accom- 
panied by  specific  appearances  on 
mucous  membranes. 


A  true  vaccinal  rash  appears  between  the 
ninth  and  fifteenth  day  after  vaccination. 
Absence  of  inoculation  chancre. 


Eruption   does   not   exhibit  specific 

acters. 
Fever  always  present. 
Evanescent. 


char- 


Vaccinosy  phili  s 


Hereditary  syphilis,  showing  itself  about 
the  time  of  vaccination 


Begins    with   local   infection   chancre   and 

indolent  bubo. 
Typical  development  in  four  stages — viz., 

incubation,   chancre,   second  incubation, 

generalization       (secondary       eruption), 

etc. 
Never  appears   earlier  than  the  ninth  or 

tenth  week  after  vaccination. 


No  chancre;  begins  with  general  phe- 
nomena. 

Has  no  typical  development  in  connection 
with  vaccination. 


Time  of  development  quite  independent 
of  vaccination.  Is  attended  by  the 
characteristic  syphilitic  bodily  aspects. 
Other  manifestations  of  hereditary 
syphilis  may  be  present.  Thej  history 
may  indicate  syphilis. 


ERYSIPELAS  73 

VARICELLA 

Synonym. — Chicken-pox. 

Definition. — A  mild,  contagious,  febrile  affection;  characterized 
by  a  moderate  fever,  and  the  appearance  of  a  vesicular  eruption 
which  drys  up  and  falls  off  in  from  three  to  five  days.  Its  cause  is 
unknown.     Children  are  most  often  attacked. 

Symptoms. — About  two  weeks  usually  elapses  between  the  period 
of  infection  and  the  onset  of  the  disease  which  is  manifested  by 
moderate  fever,  thirst,  anorexia,  and  constipation.  The  eruption 
occurs  within  twenty-four  hours  at  first  being  red  spots  which  are 
rapidly  converted  into  clear  vesicles.  The  vesicles  are  not  umbili- 
cated  or  loculated,  and  appear  in  crops.  Itching  is  intense.  The 
lesions  are  most  abundant  on  the  trunk;  they  dry  rapidly,  dropping  off 
within  a  week,  sometimes  with  pitting.  Very  rarely  the  vesicles 
become  gangrenous. 

Diagnosis. — The  slight  constitutional  disturbances  and  the  super- 
ficial and  non-umbilicated  pocks  distinguish  varicella  from  small-pox. 

The  disease  nearly  always  terminates  favorably  and  without  com- 
plications, so  that  treatment  is  unnecessary  except  possibly  to  re- 
lieve aggravated  symptoms.  For  the  itching,  a  solution  of  phenol 
(i  :  40)  may  be  sponged  on  the  skin  several  times  a  day. 

Quarantine. — A  child  who  has  been  exposed  to  chicken-pox  should 
not  be  allowed  to  return  to  school  for  three  weeks  since  date  of  such 
(last)  exposure.  And  a  child  who  has  suffered  from  the  disease 
should  not  be  allowed  to  return  to  school  for  four  weeks  after  the 
appearance  of  the  first  symptoms,  and  not  till  every  scab  has 
disappeared. 

ERYSIPELAS 

Synon3mis. — The  rose :  St.  Anthony's  fire. 

Definition. — An  acute,  specific,  infectious  disease;  characterized 
by  more  or  less  severe  febrile  reaction  and  a  peculiar  inflammation 
of  the  skin  generally  of  the  neck  and  face.  This  inflammation  ex- 
hibits a  marked  tendency  to  spread,  to  induce  serous  infiltration  and 
suppuration  of  the  areolar  tissue,  and  to  affect  the  lymphatic  vessels 
and  glands.     Recurrences  are  common. 

Cause. — The  exciting  cause  is  the  streptococcus  erysipelatis,  a 
microorganism  which  is  not  distinguishable  from  the  streptococcus 
Pyogenes.  Lowered  vitality,  existence  of  abrasions  and  wounds,  and 
the  puerperal  state  are  predisposing  factors.     It  is  contagious,  and 


74  ERYSIPELAS 

one  attack  predisposes  to  subsequent  attacks.  The  incubation  period 
varies  from  two  to  seven  days. 

Pathological  Anatomy. — The  disease  consists  essentially  of  a 
septic  inflammation  of  the  skin  and  subcutaneous  tissues,  most  fre- 
quently observed  on  the  face  and  often  directly  traceable  to  some 
intranasal  affection.  Pyemic  abscesses  of  the  internal  viscera  may 
be  found,  as  well  as  infarcts  in  the  lungs,  spleen,  and  kidneys. 

Symptoms. — The  physician  generally  sees  the  so-called  idiopathic 
erysipelas,  which  arises  independently  of  any  apparent  traumatic 
lesion.  The  onset  is  sudden  with  chill,  nausea,  vomiting,  or  convul- 
sions, malaise,  headache,  pains  in  the  limbs,  and  a  rise  of  temperature, 
104°  to  io5°F.  There  is  a  corresponding  increase  in  the  pulse  rate. 
The  tongue  is  coated  and  there  may  be  diarrhea  or  constipation.  The 
urine  is  scanty,  albuminous,  and  high-colored.  DeHrium  is  frequent 
and  in  alcoholics  resembles  delirium  tremens.  Examination  of  the 
blood  reveals  a  marked  leukocytosis. 

The  eruption  soon  follows  the  initial  chill  and  appears  as  red  spots 
which  rapidly  coalesce  forming  a  tense,  crimson  or  violet -hued,  shin- 
ing area.  This  area  is  swollen  and  firm,  is  hot  and  tender  to  the 
touch,  and  has  a  sharply  defined  border.  Vesicles  and  blebs  fre- 
quently develop.  The  patient  complains  of  heat,  tingling,  burning, 
and  itching  in  the  affected  tissues.  The  edema  of  the  surrounding 
parts  is  marked  and,  when  the  face  is  involved,  distorts  the  features. 
The  eruption  begins  to  subside  after  five  or  six  days  followed  by  moder- 
ate desquamation  and  dechne  of  the  fever  by  lysis.  When  the 
eruption  is  attended  by  marked  infiltration  of  the  areolar  tissues  the 
term  phlegmonous  erysipelas  is  employed.  When  the  affection  is 
migratory  in  character,  disappearing  in  one  place  and  appearing  in 
another,  it  is  called  erysipelas  amhulans. 

Complications. — Complications  are  uncommon.  Thrombosis  of 
the  cerebral  vessels,  edema  of  the  larynx,  septicemia,  pneumonia, 
endocarditis,  pleurisy,  pericarditis,  and  rheumatism  have  been  ob- 
served in  the  course  of  this  disease. 

Diagnosis. — The  irregular  fever,  the  early  spreading  eruption  with 
burning,  swelling,  tension  and  a  sharply  defined  border,  and  the 
albuminous  urine  will  distinguish  erysipelas  from  the  eruptive  fevers, 
eczema,  and  erythema. 

Prognosis. — The  outlook  is  favorable  except  in  alcoholics,  puer- 
peral women,  infants,  and  debilitated  subjects;  it  is  also  worse  in  the 
migratory  form  of  the  disease. 


MUMPS  75 

Treatment. — Patients  with  erysipelas  should  be  isolated,  par- 
ticularly from  all  surgical  and  obstetrical  cases.  The  disease  is 
self-limited,  and  many  cases  of  the  so-called  idiopathic  erysipelas 
get  well  without  any  treatment  whatever.  In  mild  cases  the  internal 
administration  of  a  laxative  and  the  tincture  of  the  chloride  of  iron 
with  the  local  application  of  vaseline,  ichthyol  ointment  (3j  to  5j), 
or  bismuth  oleate  will  suffice.  In  severe  cases  the  patient  should  be 
supported  by  the  use  of  quinine  sulphate,  gr.  ij  (0.13  gm.),  extract 
of  belladonna,  gr.  yi  (0.016),  and  tincture  of  the  chloride  of  iron, 
TTlx  to  XX  (0.6  to  1.3  c.c.)  every  third  hour,  A  liquid  but  nutritious 
diet  should  be  ordered.  Alcohol  may  be  required,  particularly  in 
the  old  and  feeble.  Nervous  symptoms  should  be  combated  with 
appropriate  measures  as  they  arise. 

In  the  early  stages  there  may  be  used  pilocarpine  hydrochloride, 
gr.  yi  (o.oii  gm.),  hypodermically,  or  fluidextract  of  pilocarpine, 
ITtxx  to  XXX  (1.3  to  2  c.c),  every  three  hours  until  free  sweating  oc- 
curs; after  this  the  interval  should  be  increased  to  six  hours.  Iodide 
of  potassium  and  the  antistreptococcic  serum  have  also  yielded  good 
results. 

Local  Treatment. — Peroxide  of  hydrogen,  glycerite  of  boroglycerin, 
lead-water  and  laudanum  (4  parts  of  liquor  plumbi  subacetatis 
dilutus,  U.S. P.,  to  2  of  laudanum),  carbolic  acid  lotion  (5ij  to  the 
pint),  or  silver  nitrate  solution  (gr.  xx  to  the  ounce)  may  be  applied. 
Ointments  containing  ichthyol,  zinc  oxide,  mercurial  ointment, 
eucalyptol,  or  soluble  silver  are  also  beneficial.  The  application  of 
tincture  of  iodine  or  solid  silver  nitrate  to  the  periphery  often  checks 
extension  of  the  disease.  In  deep-seated  varieties,  scarifying  and 
multiple  incisions  will  be  necessary. 

MUMPS 

Synonym. — Parotitis. 

Definition. — An  acute,  specific,  infectious  inflammation  of  one  or 
both  parotid  and  other  salivary  glands  and  the  surrounding  connec- 
tive tissue,  with  a  tendency  to  migrate  into  the  testes  or  mammae, 
characterized  by  pain,  swelling,  and  disordered  function  of  the  glands. 
The  affection  is  contagious. 

Causes. — The  specific  cause  is  at  present  unknown.  It  occurs  in 
epidemics,  although  isolated  cases  are  seen.  Males  are  more  liable 
than  females.     The  most  common  ages  are  between  five  years  and 


76  -  MUMPS 

puberty.  As  a  rule  it  occurs  but  once  in  the  same  individual.  The 
period  of  incubation  is  about  fourteen  days. 

Pathological  Anatomy. — There  is  inflammation  of  one  or  both 
parotid  glands,  and  in  severe  epidemics  the  cellular  tissue  pervading 
the  gland  is  involved.  The  catarrhal  inflammation  begins  in  the 
gland  ducts  and  rapidly  extends  to  the  gland  proper.  These  are 
congestion,  swelling,  and  an  infiltration  of  serous  fluid,  the  latter 
extending  to  the  adjacent  tissues.  The  swelling  may  suddenly 
reach  an  enormous  size  and  as  suddenly  decline,  the  gland  returning 
to  its  normal  condition,  or,  rarely,  an  abscess  results,  with  partial 
or  complete  destruction  of  the  gland.  Occasionally  the  submaxillary 
gland,  the  ovaries,  mammas,  and  testes  are  involved. 

Secondary  parotitis  occurs  as  a  complication  in  severe  blood-poison- 
ing, as  in  pyemia,  typhoid,  or  typhus  fevers,  or  diphtheria.  The  usual 
termination  of  secondary  parotitis  is  by  suppuration  and  destruction 
of  gland-structure. 

S3niiptoms. — The  onset  is  rather  sudden,  attended  by  malaise, 
chill,  fever,  ioi°  to  103 °F.,  quick  pulse,  headache,  dry  skin,  scanty 
urine,  followed  within  a  day  or  two  by  pain  below  and  in  front  of  the 
ear,  with  stiffness  at  the  angles  of  the  jaw,  swelling  of  the  parotid 
and  other  salivary  glands,  pain  increased  by  moving  the  jaws,  with 
general  edema  of  the  affected  side  of  the  face,  at  times  the  skin  being 
reddened.  Salivation  is  frequent  and  occasionally  deafness  occurs. 
The  swelling  and  other  glandular  symptoms  subside  about  the  seventh 
to  the  tenth  day,  to  be  followed  by  restoration  to  health  or,  what  is 
more  common,  the  involvement  of  the  opposite  gland. 

Complications. — Orchitis  is  the  most  frequent  complication,  occur- 
ring in  about  one-third  of  the  cases,  but  rarely  before  the  age  of 
puberty.  It  usually  occurs  about  the  eighth  day;  and  one  or  both 
testicles  may  be  involved. 

Vulo-vaginitis  sometimes  occurs  in  girls;  the  mammary  glands 
are  also  occasionally  involved.  Mastitis  has  also  been  seen  in 
boys. 

At  any  time  during  the  disease  metastasis  to  the  mammas,  ovaries, 
or  testes  is  apt  to  occur,  when  the  symptoms  peculiar  to  such  affec- 
tions will  be  added.  It  has  been  noted  that  a  continuance  of  the 
temperature  after  the  decline  of  the  parotid  symptoms  has  begun 
usually  is  significant  of  metastasis.  It  is  claimed  that  the  involve- 
ment of  other  organs  during  the  course  of  mumps  is  not  an  example 
of  metastasis,  but  is  a  true  transfer  of  the  disease. 


DIPHTHERIA  77 

Prognosis. — In  simple  cases  the  prognosis  is  favorable.  Metas- 
tasis to  other  organs  may  result  in  atrophy  or  impairment  of  their 
functions. 

Treatment. — Isolation  with  rest  and  liquid  diet  are  the  first  indi- 
cations. If  the  temperature  is  high,  fever  mixtures  may  be  employed. 
Locally,  hot  fomentations  and  ointments  of  belladonna,  mercury, 
and  guaiacol,  alone  or  combined,  are  of  value  in  relieving  distress. 
If  the  condition  tends  to  persist,  blisters  should  be  applied  and  potas- 
sium iodide  administered.  Orchitis  will  require  hot  or  cold  local 
applications  and  mercury  and  belladonna  ointments  and  the  internal 
use  of  tincture  of  Pulsatilla,  TTliij  to  v  (0.2  to  0.3  c.c),  every  hour,  or 
potassium  iodide;  the  testicles  should  be  raised. 

Quarantine. — A  child  who  has  been  exposed  to  mumps  should  not 
be  allowed  to  go  to  school  until  twenty-four  days  have  elapsed  since 
the  date  of  the  (last)  exposure.  A  child  who  has  had  mumps  should 
not  be  allowed  to  return  to  school  for  at  least  three  weeks  since  the 
beginning  of  the  symptoms,  and  only  then  if  the  swelling  has  disap- 
peared for  at  least  a  week. 

DIPHTHERIA 

Synonyms. — Membranous  croup;  true  croup;  malignant  quinsy; 
membranous  angina. 

Nomenclature. — The  term  diphtheria  is  applied  by  bacteriologists 
to  any  condition  (even  simple  sore  throat)  in  which  the  Klebs-Loeffler 
bacillus  is  found;  and  pseudodiphtheria,  or  diphtheroid,  when  the 
Klebs-Loeffler  bacillus  is  not  present,  no  matter  how  severe  the  other 
signs  and  constitutional  disturbances  may  be. 

Membranous  croup  or  true  croup  is  laryngeal  diphtheria;  spasmodic 
croup  or  false  croup,  or  catarrhal  croup,  is  a  form  of  laryngitis  (see 
page  479).  As  Greene  well  says:  ^^ Membranous  croup  has  properly 
been  shelved  by  modern  methods  of  diagnosis  and  replaced  by  laryn- 
geal diphtheria,  which  in  99  per  cent,  of  such  cases  is  the  proper 
descriptive  term." 

Definition. — An  acute,  specific,  infectious  disease;  both  epidemic 
and  contagious,  beginning  by  an  affection  of  the  throat,  characterized 
by  a  local  exudation  and  glandular  enlargements ;  attended  with  fever, 
constitutional  symptoms,  great  prostration  of  the  vital  powers,  and 
albuminuria,  and  often  having  for  its  sequelae  various  paralyses. 

Causes. — A  specific  germ,  the  Klebs-Loeffler  bacillus.  The  bacil- 
lus in  its  growth  produces  a  potent  toxic  substance — a  toxalbumin 


78  DIPHTHERIA 

(whose  composition  is  unknown) — the  absorption  of  which  produces 
the  disease,  and  not  the  organism  itself.  The  diphtheria  bacillus  is 
associated  with  other  pathogenic  bacteria,  scuh  as  streptococcus 
pyogenes,  staphylococcus  pyogenes  aureus  and  albus,  micrococcus 
lanceolatus,  and  bacillus  coli  communis.  It  is  preeminently  a  disease 
of  childhood.  It  is  apt  to  recur  in  those  who  have  once  been  affected. 
All  conditions  of  bad  hygiene  increase  its  virulence  and  diffusion,  al- 
though the  chief  cause  of  its  spread  is  contagion.  Nasal,  pharyngeal, 
and  laryngeal  catarrh,  produce  a  soil  capable  of  promoting  the  growth 
of  the  bacillus  and  its  toxin.  The  poison  exists  in  the  exudation  and 
secretions  of  the  fauces  and  saHva,  and  floats  in  the  atmosphere  at  a 
considerable  distance  from  the  patient.  The  virus  adheres  to  the 
clothing,  the  bedding,  the  furniture,  and  the  room  which  the  patient 
occupied.  The  disease  is  highly  contagious  and  may  be  contracted  ( i ) 
by  direct  contact  with  an  infected  person;  (2)  by  contact  with  infected 
articles — fomites;  (3)  from  the  discharge  of  the  nose  and  throat  of 
persons  who  have  recently  had  the  disease;  (4)  from  the  throats  of 
^^ diphtheria  carriers" — ^persons  who  show  no  signs  of  the  disease.  The 
period  of  incubation  is  from  two  to  seven  days. 

Pathological  Anatomy. — The  diphtheritic  or  croupous  inflammation 
differs  from  the  catarrhal  form  in  that  the  exudation  is  not  only 
upon,  but  also  within,  the  substance  of  the  mucous  membrane. 
At  first  there  is  redness,  which  may  begin  in  any  part  of  the  throat, 
associated  with  sweUing  and  an  increased  secretion  of  viscid  mucus. 
The  redness  spreads  over  the  entire  mucous  surface,  when  the  exuda- 
tion makes  its  appearance,  at  first  giving  the  affected  mucous  mem- 
brane a  glazed  appearance,  which  is  very  characteristic.  The  deposit 
may  commence  from  one  of  several  points,  such  as  one  tonsil,  the 
soft  palate,  or  the  back  of  the  fauces,  which,  however,  speedily 
extend  and  coalesce,  forming  extensive  patches,  or  cover  uniformly 
the  entire  surface.  The  patches  are  of  variable  thickness,  which  is 
increased  by  successive  layers  being  formed  underneath. 

The  color  is  usually  gray,  white,  or  slightly  yellow,  but  may  be 
brownish  or  blackish,  the  consistence  ranging  from  "cream  to  wash 
leather."  On  removing  the  membrane,  which  is  accomplished  with 
more  or  less  difficulty,  a  raw  bleeding  surface  is  exposed,  and  at  times 
an  ulcer,  which  is  speedily  covered  with  a  fresh  deposit.  If  the 
exudation  separates  itself,  it  is  either  not  renewed  at  all  or  only  in 
thinner  films.  The  exudation  or  membrane,  examined  by  the  micro- 
scope, is  composed  of  fibrin,  pus  corpuscles,  epithelial  granular  cells, 


DIPHTHERIA  79 

and  the  Klebs-Loeffler  bacillus  and  other  pathogenic  bacteria.  It 
is  believed  to  be  a  product  of  coagulation  necrosis. 

Oertel  described  the  local  changes  as  follows:  "The  poison  first 
induces  a  necrosis  of  the  cells  with  which  it  comes  in  contact;  the 
superficial  epithelium  thus  first  disappears.  The  deeper  cells  become 
similarly  affected,  and  a  zone  of  inflammation  forms  around  the  dead 
cells;  the  membrane  thus  is  really  a  mass  of  dead  cells  under- 
going hyaline  degeneration,  and  mingled  with  fibrin,  and  it  presents 
the  peculiar  laminated  appearance  considered  characteristic.  The 
neighboring  lymphatic  glands  become  much  enlarged." 

If  the  larynx,  trachea,  or  nasal  mucous  membranes  participate 
in  the  disease,  the  croupous  and  not  the  diphtheritic  form  of  inflamma- 
tion occurs. 

The  lymphatic  glands  of  the  neck,  whose  vessels  originate  in  the 
faucial  tissues,  are  enlarged  and  inflamed  and  contain  large  numbers 
of  bacteria,  probably  originating  as  the  result  of  decomposition. 

The  muscular  tissue  of  the  heart  becomes  soft,  is  easily  torn,  and  its 
fibrillse  are  far  advanced  in  granular  degeneration.  Ulcerative  endo- 
carditis has  been  frequently  observed.  The  kidneys  undergo  a 
granular  degeneration  in  severe  attacks.  The  blood  undergoes  altera- 
tion, becoming  black  and  fluid. 

S3miptoms. — As  is  commonly  seen  in  contagious  diseases,  the  symp- 
toms vary  in  intensity  in  different  cases,  the  prominent  symptoms  be- 
ing often  disproportionate  to  the  gravity  of  the  attack.  The  invasion 
may  be  mild,  with  rigors  succeeded  by  moderate  fever,  headache, 
languor,  loss  of  appetite,  stiffness  of  the  neck,  tenderness  about  the 
angles  of  the  jaw,  or  slight  soreness  of  the  throat.  In  other  cases  the 
invasion  is  more  abrupt  and  severe,  with  chilliness  followed  by  great 
febrile  reaction,  103°  to  io5°F.,  pain  in  the  ear,  aching  in  the  limbs, 
loss  of  strength,  painful  deglutition,  and  swelling  of  the  neck,  compell- 
ing the  patient  to  take  to  bed  from  the  onset.  The  appetite  is  poor, 
the  tongue  slightly  coated,  sometimes  more  or  less  exudation  appearing 
upon  it,  the  bowels  either  regular  or  slightly  relaxed.  The  pulse  at 
first  full  and  strong,  soon  becomes  either  rapid  or  slow,  but  cormpes- 
sible.  The  urine  is  scanty,  high-colored,  and  contains  albumin. 
Prostration  and  weariness  are  present  to  a  marked  degree. 

The  local  symptoms  in  the  majority  of  cases  are  associated  with  the 
throat.  The  patient  often  complains  of  a  frequent  and  persistent 
desire  to  hawk,  in  order  to  clear  the  throat.  On  inspection,  the  fauces 
are  seen  red  and  swollen  and  more  or  less  covered  with  a  film  of 


So  DIPHTHERIA 

diphtheritic  exudation,giving  a  glazed  appearance,  soon  followed  by  the 
dirty-white  membrane;  sometimes  the  tonsils  and  uvula  are  greatly 
swollen  and  spotted  with  exudation.  Removal  of  the  false  membrane 
exposes  to  view  a  raw  bleeding  surface  over  which  a  new  membrane 
promptly  forms.  In  severe  cases  more  or  less  ulceration  or  sloughing 
may  be  observed.  Not  infrequently  fragments  of  exudation,  the 
false  membrane,  are  expectorated,  with  particles  of  the  ulcerated 
tissues,  having  an  offensive  odor,  which  is  transmitted  to  the  breath. 
The  lymphatic  glands  of  the  neck  are  enlarged  and  tender,  and  in 
severe  cases  the  tissues  of  the  neck  are  greatly  tumefied. 

Extension  to  the  nasal  cavities  causes  a  sanious  and  offensive 
discharge  from  the  nose,  with  attacks  of  epistaxis.  Constitutional 
reaction  is  marked.  Enlargement  of  the  deep  faucial  glands  at  the 
angle  of  the  jaw  is  characteristic  of  this  form  of  the  disease. 

Extension  to  the  larynx  is  indicated  by  hoarseness  or  complete 
loss  of  voice,  croupy  cough  and  obstructive  dyspnea,  which  often 
becomes  urgent,  the  breathing  being  noisy  and  stridulous  and  subject 
to  paroxysmal  exacerbations.  If  the  inflammation  extends  to  the 
bronchi,  the  breathing  becomes  still  more  embarrassed.  This  variety 
runs  a  rapid  course  and  often  terminates  in  death  by  suffocation. 

Duration. — The  disease  lasts  from  two  to  fourteen  days,  the 
average  being  about  nine  days,  although  complications  and  sequels 
may  prolong  its  course.     Relapses  are  not  uncommon. 

Complications  and  Sequels. — Eruptions  on  the  skin,  such  as 
erythema,  urticaria,  and  purpura  may  occur  in  the  course  of  the 
disease,  and  while  not  of  serious  importance  may  lead  to  errors  in 
diagnosis.  The  most  common  complication  is  nephritis.  Albumin- 
uria is  present  in  nearly  all  severe  cases  of  diphtheria,  but  when  it  is 
associated  with  blood  casts,  epitheUal  casts,  and  scanty  urine,  the 
presence  of  parenchymatous  nephritis  is  indicated.  Capillary 
bronchitis,  bronchopneumonia,  endocarditis,  arthritis,  meningitis, 
and  otitis  media  also  occur  as  complications. 

After  a  severe  attack  patients  often  remain  anemic  and  cachectic 
for  an  indefinite  period.  Paralysis,  due  to  toxic  neuritis,  is  a  common 
sequel  (lo  to  20  per  cent.)  following  the  mild  as  well  as  the  severe 
attacks.  It  may  appear  at  the  end  of  the  first  week,  but  usually 
presents  itself  after  convalescence  has  been  established.  It  most 
frequently  affects  the  pharyngeal  muscles  and  palate  seriously  inter- 
fering with  deglutition  and  impairing  the  voice.  Anesthesia  of  the 
pharyngeal  mucous  membrane  occurs  coincidentally .    Taste  and  smell 


DIPHTHERIA  _  8 1 

are  often  abolished  and  not  recovered  till  some  time  after  recovery 
from  the  disease.  The  eye  muscles  are  affected  next  in  frequency. 
Facial  paralysis  and  palsy  of  the  extremities  may  also  occur.  Sensa- 
tion and  reflexes  are  diminished  in  the  paralyzed  parts.  Neuritis  of 
the  cardiac  nerves  is  not  infrequent,  resulting  in  brachycardia, 
tachycardia,  and  even  sudden  cessation  of  the  heart's  action,  and 
death.  The  pulsations  have  been  known  to  fall  to  20  per  minute. 
Multiple  neuritis  rarely  occurs  as  a  sequel. 

Diagnosis. — The  onset,  course,  throat  symptoms,  prostration, 
and  the  results  of  microscopic  examination  of  cultures  taken  from  the 
throat  are  the  characteristics  of  this  disease. 

Intense  follicular  tonsillitis  due  to  streptococcic  infection  may  be 
mistaken  for  diphtheria.  This  exudate  usually  shows  no  tendency 
to  spread  and  is  in  most  cases  limited  to  one  tonsil;  dropping  out  at 
the  end  of  the  second  or  third  day,  and  leaving  a  clean-cut  ulcer  which 
heals  rapidly.     Microscopic  examination  is  diagnostic. 

Scarlet  fever  may  be  confused  with  diphtheria,  but  the  characteristic 
eruption,  strawberry  tongue,  rapid  pulse,  and  the  absence  of  the 
diphtheria  bacillus  will  serve  to  distinguish  them.  They  may  exist 
coincidentally  in  the  same  patient. 

Many  cities  in  the  United  States  now  offer,  through  their  health 
bureaus,  to  make  bacteriological  examinations  for 
physicians  in  all  cases  of  possible  diphtheria.  Out- 
fits are  left  at  stations.  They  consist  of  a  box  con- 
taining a  tube  of  blood-serum  and  another  contain- 
ing a  sterilized  swab.  The  following  directions 
are  issued  by  the  Philadelphia  Board  of  Health: 

"Inoculations  should  be  made  by  rubbing  the 
cotton  swab  attached  to  the  end  of  the  wire  con-       „        ,     ^.  ,  ,    . 

.  Fig.   16. — Diphtheria 

tamed  m  the  test-tube  gently,  but  freely,  against   bacillus   (bacillus  diph- 

.   .,  1  T    ,  1,1  1  .        .,  ,1         theriae)        of      Loeffler. 

any  visible  exudate,  and  then  drawing  it  over  the  •  {From  Greene's  Medical 
surface  of  the  culture-medium  without  breaking  ^o^snosts.) 
the  surface  of  the  latter.  The  swab  should  then  be  replaced  in  the 
tube  from  which  it  was  taken,  and  both  tubes  be  replugged  and  put 
back  into  the  box.  Return  the  box  to  the  station  from  which  it  was 
obtained  as  soon  as  possible  or  bring  it  directly  to  the  laboratory. 
The  tubes  will  be  collected  every  afternoon,  examined  the  fol- 
lowing morning,  and  reports  will  be  mailed  by  one  o'clock  p.m.  The 
attending  physician  can  obtain  information,  however,  by  telephoning 
directly  to  the  laboratory  after  that  hour." 


82  DIPHTHERIA 

Prognosis. — Always  grave,  but  more  so  in  children  than  in  adults. 
Its  gravity  in  the  majority  of  cases,  is  proportionate  to  the  local 
symptoms.     The  average  mortality  is  now  about  lo  per  cent. 

Favorable  indications  are  moderate  fever,  strength  slightly  im- 
paired, a  good  constitution,  and  moderate  exudation. 

Unfavorable  indications  are  high  fever,  great  depression,  spreading 
exudation,  great  swelUng  of  the  cervical  glands,  large  am^ounts  of 
albumin,  extension  to  larynx  and  nasal  mocous  membranes,  hemor- 
rhages from  the  fauces  and  nose,  and  an  epidemic  character. 

Treatment. — Antitoxin  serum  is  indicated  in  all  cases.  It  should 
be  administered  at  once  if  there  is  any  likelihood  of  the  disease  being 
diphtheria;  do  not  wait  for  the  bacteriological  diagnosis.  It  may  also 
be  employed  as  a  prophylactic  measure  in  those  exposed  to  the 
contagion.  The  injections  should  be  made  where  the  skin  is  loose, 
and  at  points  that  will  not  interfere  with  the  patient's  comfort.  The 
dose  is  estimated  in  antitoxic  units  and  not  by  the  unit  of  the  serum. 
The  immunizing  dose  is  from  500  to  1000  units  (according  to  the  age 
of  the  person  to  be  protected) ;  the  curative  dose  is  from  3000  to  5000 
units. 

"In  favorable  cases,  after  twenty-four  hours  have  passed,  the 
temperature  will  not  have  risen ;  the  pulse  will  be  slower ;  the  membrane 
will  not  have  spread;  the  mucous  membrane  at  the  edge  of  the  exuda- 
tion will  be  bright  red  in  color.  There  will  be  a  feeling  of  diminished 
discomfort  and  revival  of  spirits.  These  are  favorable  signs,  and  a 
second  dose  need  not  be  administered.  A  second  dose  is  adminis- 
tered after  twenty-four  hours  if  the  temperature  has  risen,  if  the 
membrane  is  spreading,  and  if  the  general  condition  of  the  patient  is 
not  so  good  as  at  the  previous  injection.  As  might  be  expected,  im- 
provement is  more  rapid  in  mild  cases"  (Tyson). 

It  must  be  remembered  that  there  is  no  way  of  estimating  the 
"dosage"  of  antitoxin  required;  hence  it  should  be  administered  till 
the  characteristic  effect  is  produced — shriveling  of  the  membrane, 
diminution  of  the  nasal  discharge  and  of  fetid  odor,  and  a  generally 
improved  condition  of  the  patient.  In  addition  to  the  antitoxin 
treatment  supportive  measures  are  indicated  to  combat  the  profound 
prostration.  The  patient  should  be  isolated  and  means  taken  to  pre- 
vent spreading  of  the  disease.  Rest  in  bed  with  the  employment  of  a 
diet  composed  of  milk,  eggs,  broths,  oysters,  etc.,  every  two  or  three 
hours  is  indispensable.  If  deglutition  is  painful  or  difficult,  resort 
must  be  had  to  nutritive  enemas,  such  as  the  following: 


DIPHTHERIA  83 

I^.     Milk Bj  30  c.c. 

Spts.  frumenti 5iv  15  c.c. 

Egg One. 

M.  S. — Add  a  small  quantity  of  salt,  mix  thoroughly,  and  use 
as  directed. 

The  room  in  which  the  patient  is  confined  should  be  well  ventilated 
and  its  temperature  maintained  at  an  average  of  70°?.  The  atmos- 
phere should  be  rendered  warm  and  moist  by  generating  steam 
from  an  ordinary  hot-water  kettle  or  by  slaking  lime  in  the  sick-room. 
In  the  laryngeal  form  direct  inhalations  of  hot-water  vapor  are  in- 
dicated. Ice-pellets  placed  in  the  mouth  afford  great  reHef  during 
these  inhalations.  Sponges  dipped  in  hot  water  and  applied  to 
the  angles  of  the  jaw  are  also  beneficial.  To  prevent  dissemina- 
tion of  the  poison  by  the  exhaled  air,  Dr.  J.  Lewis  Smith  advises 
the  following:  Add  four  ounces  of  the  following  sokition  to  one 
quart  of  water  and  allow  this  to  simmer  constantly,  near  the  patient, 
in  a  broad-surfaced  tin  or  zinc  wash-basin:  I^.  Olei  eucalypt., 
acidi  carbolici,  aa  fjB  (30  c.c);  spirit,  terebinthinae,  f^viij  (240  c.c). 
M.  The  vapor  is  strong,  penetrating,  and  prophylactic,  but  not 
unpleasant.  In  hot  weather,  or  when  a  fire  is  not  convenient, 
saturate  cloths  a  foot  square  with  the  same  solution  and  place  them 
on  paper  on  the  bed  of  the  patient. 

Quite  recently  the  Schick  reaction  has  attracted  some  attention. 
Schick  uses  a  toxin  solution  intradermically  to  determine  the  sus- 
ceptibility of  a  patient  to  diphtheria;  he  injects  i  c.c.  of  toxin  solution, 
and  if  the  patient  is  not  immune  a  reaction  occurs  somewhat  similar 
to  the  von  Pirquet  reaction  in  tuberculosis. 

The  medical  treatment  is  general  and  local.  Internally,  stimulants 
should  be  used  boldly  from  the  onset;  it  is  a  mistake  to  wait  for 
signs  of  debility  before  using  alcohol  in  this  disease.  Other  stimu- 
lants, such  as  strychnine,  quinine,  digitalis,  nitroglycerin  and  caffeine 
should  also  be  employed.  Tincture  of  the  chloride  of  iron  and  bi- 
chloride of  mercury  are  used  frequently  in  the  following  combination: 

I^.     Hydrargyri  chloridi  corrosivi  gr.  ^-^g  0.0015        gm. 

Tinct.  ferri  chloridi TTlv  to  x  o. 3  to  o . 6  c.c. 

Glycerini lUx  0.6  c.c. 

Aqu^ f5j  4-0  c.c. 

M.  S. — Every  hour  or  two,  well  diluted. 

The  addition  of  tincture  of  belladonna,  TUj  to  v  (0.06  to  0.3  c.c), 
to  each  dose  increases  its  efficiency. 


84  DIPHTHERIA 

A  combination  of  iron  and  potassium  chlorate  in  full  doses,  fre- 
quently repeated,  seems  to  modify  the  course  of  the  malady  and  has 
the  additional  advantage  of  acting  locally  as  it  is  swallowed. 

The  following  formula  is  frequently  used: 

I^.     Tinct.  ferri  chlorid TTtv  to  x         o .  3  to  o .  6  c.c. 

Potassii  chlorat gr.  iij  to  v     o .  2  to  o .  3  gm. 

Glycerini fSss  2.0  c.c. 

Syr.  zingib q.  s.  ad  f  5  j  to  ij  ad  4 .  o  to  8 .  o  c.c. 

M.  vS. — In  water  every  three  hours,  for  a  child  of  two  or  three 
years. 

Calomel  in  small  doses  (gr.  3^),  combined  with  sodium  bicarbonate 
every  hour  until  spawn-like  stools  are  produced,  is  beneficial,  espe- 
cially in  cases  showing  a  tendency  to  spread  toward  the  larynx.  In- 
deed, a  tolerance  to  calomel  seems  to  exist  in  laryngeal  diphtheria. 

In  all  cases  the  bowels  should  be  kept  regular  by  the  use  of  laxatives 
and  the  urine  should  be  carefully  watched  throughout  the  entire 
course  of  the  disease;  diminution  in  the  amount  with  considerable 
albumin  is  of  grave  significance. 

Locally,  measures  should  be  employed  tending  toward  the  preven- 
tion of  the  spread  of  the  infection.  It  is  impossible  to  dissolve  the 
false  membrane  in  the  throat  by  applications.  Peroxide  of  hydrogen 
(50  per  cent.)  or  Dobell's  solution,  used  in  a  spray  or  on  a  cotton 
swab  or  sponge,  should  be  freely  employed  every  hour  to  keep  the 
mouth  and  pharynx  as  aseptic  as  possible.  Bichloride  of  mercury 
(i  to  4000),  carbolic  acid  (3  per  cent,  solution  in  equal  parts  of 
glycerin  and  water),  salicylic  acid  (i  to  300),  thymol  (i  to  2000), 
lactic  acid  (30  gr.  to  the  ounce),  trypsin  (30  gr.  to  the  ounce),  and 
papoid  may  also  be  used  as  local  applications.  The  addition  of 
tartaric  acid  to  bichloride  of  mercury  increases  its  germicide  proper- 
ties. In  a  I  to  500  solution  the  proportions  are  as  follows:  bichloride 
of  mercury,  gr.  3.75  (0.25  gm.),  tartaric  acid,  gr.  19.25  (1.25  gm.), 
water,  4  f§  (120  c.c).  The  following  formulas  are  of  value  for 
local   use: 

I^.     Acidi  carbolici TTlxx  i .  3  c.c. 

Tinct.  ferri  chlorid f  5iv  15 -O  c.c. 

Glycerini f  §j  30.0  c.c. 

Aq.  destil f§j  30.0  c.c. 

M.  S. — Apply  locally  by  means  of  a  swab  every  three  hours. 


DIPHTHERIA  6^ 

I^.     Potass,  chlorat 5iv  15.0  gm. 

Acid,  carbol gr.  ij  to  iv     o.  13  to  0.26  gm. 

Tinct.  myrrh fgj  30.0  c.c. 

Inf.  cinchonae fgij  60.0  c.c. 

M.  S. — Use  as  a  gargle  or  apply  to  throat  with  a  cotton  swab. 

I^.     Menthol 10      gm. 

Toluol q.  s.  ad  36      c.c. 

M.     Et  adde. 

Ferri  sesquioxid 4      c.c. 

Alcohol  absolut 60      c.c. 

M.  S. — Loeffler's  Solution.     Apply  to  throat  by  means  of  cotton 
swab. 

Avoid  struggling  with  children  in  an  effort  to  forcibly  spray  or 
gargle  the  throat  and  nose;  instead,  add  glycerin  to  their  internal 
medicine,  and  allow  no  liquids  for  some  time  after  its  administration. 

In  laryngeal  diphtheria,  the  general  treatment,  especially  the 
mercurial  medication,  should  be  the  same.  The  patient  should 
inhale  the  vapor  of  slaking  lime  and  lime-water  (3  parts)  and  glycerin 
(i  part).  Emetics  are  often  prescribed  to  promote  the  expulsion 
of  the  false  membrane;  for  this  purpose  wine  of  ipecac  may  be  used. 
When  suffocation  is  threatened  from  the  laryngeal  obstruction, 
intubation  or  tracheotomy  should  be  performed  immediately. 

Nasal  diphtheria  requires  the  same  general  treatment  as  the  f  aucial 
variety,  with  addition  of  thorough  cleansing  of  the  nasal  cavities 
every  two  hours  with  peroxide  of  hydrogen,  carbolic  acid,  boric 
acid  solution,  Dobell's  solution,  potassium  chlorate,  or  the  following: 

I^.     Sodii  sulphit 5iij  12  gm. 

Glycerini f  5ij  8  c.c. 

Aquae f  Biv  120  c.c. 

M.  S. — Use  locally  as  directed. 

The  nozzle  of  the  syringe  must  be  passed  in  horizontally,  not 
vertically;  or  the  fluid  will  return  through  the  same  nostril. 

During  convalescence  in  all  forms,  stimulation  should  be  continued 
to  prevent  sudden  heart-failure.  Iron,  quinine,  strychnine,  cod- 
liver  oil,  arsenic,  etc.,  will  be  necessary  to  combat  the  attendant 
anemia  and  restore  strength.  Paralysis  will  necessitate  massage 
and  electricity  in  addition. 

Prophylaxis. — As  in  other  contagious  diseases  the  patient  should 
be  isolated  in  a  room  stripped  of  all  unnecessary  furniture  and  draper- 


86  Vincent's  angina 

ies.  Everything  used  by  the  patient  or  with  which  he  comes  m 
contact  should  be  reserved  for  him  alone.  Instruments,  tongue 
depressors,  spoons,  etc.,  should  be  boiled  or  kept  immersed  in  carbolic 
acid  solution.  Bed  linen,  clothing,  etc.,  should  be  steriHzed  by  boil- 
ing or  by  exposure  to  superheated  steam.  Formaldehyde  gas  is 
employed  for  disinfection  of  the  room,  (after  the  patient's  removal) 
and  its  contents.  All  attendants  should  wear  a  gown  of  washable 
material  on  entering  the  sick-room,  discarding  the  same  on  leaving 
it.  The  hands  should  be  washed  and  immersed  in  an  antiseptic 
solution  before  leaving  the  room.  After  convalescence  is  established 
the  patient  should  be  washed  with  soap  and  hot  water  and  then 
with  alcohol  (50  per  cent.),  carbolic  acid  solution  (2  per  cent.), 
or  bichloride  of  mercury  (i  to  2000  solution)  for  three  days  in  succes- 
sion. The  hair  should  be  similarly  treated  or,  in  some  cases,  cut  off. 
Quarantine. — A  child  who  has  been  exposed  to  diphtheria  should 
not  be  allowed  to  go  to  school  for  twelve  days  after  such  (last  expo- 
sure). And  a  child  who  has  had  diphtheria  should  not  be  allowed 
to  return  to  school  for  four  weeks,  provided  that  then  there  are  no 
discharges,  that  bacteriological  examinations  of  smears  from  the 
nose  and  throat  are  repeatedly  negative,  and  that  the  urine  is  free 
from  albumin. 

VINCENT'S  ANGINA 

Definition  and  Etiology. — A  form  of  sore  throat  due  to  two  organ- 
isms, the  fusiform  bacillus  and  the  spirochcBta  darticola.  It  occurs 
chiefly  in  children  and  young  adults;  the  eruption  of  the  wisdom 
teeth  is  said  to  be  a  predisposing- factor.  Bad  hygiene,  and  the  use 
of  alcohol  and  tobacco  are  favoring  conditions. 

Symptoms. — Two  forms  are  recognized:  (i)  The  ulceromembranous 
variety,  which  is  the  most  common  (occurring  in  about  98  per  cent. 
of  the  cases)  and  in  which  both  the  bacillus  and  spirochete  (or 
spirillum)  are  found.  In  this  form  there  are  malaise,  sore  throat, 
headache,  fever,  dysphagia,  and  fetid  breath;  later  ulceration  of  one 
or  both  tonsils  occurs.  (2)  The  diphtheroid  variety,  which  occurs 
in  about  2  per  cent,  of  cases  only.  This  form  is  due  to  the  fusiform 
bacillus  alone,  and  is  characterized  by  a  distinct  false  membrane  or 
an  inflamed  base.  Otherwise  the  symptoms  are  the  same  as  those 
found  in  the  ulceromembranous  variety. 

Diagnosis. — A  smear  and  culture  will  decide  whether  the  case  is 
one  of  diphtheria  or  not. 


GLANDERS   AND   FARCY  87 

Treatment. — An  antiseptic  mouth  wash,  and  the  application  of 
tincture  of  iodine  twice  a  day  are  indicated.  The  disease  is  not 
amenable  to  antitoxin.  On  account  of  the  presence  of  a  spirillum, 
salvarsan  has  been  tried,  and  (it  is  claimed)  with  satisfactory  results. 

GLANDERS  AND  FARCY 

Definition. — An  infectious  disease  of  the  horse,  communicable  to 
man  and  some  domestic  animals,  but  not  to  cattle;  characterized 
by  nodular  growths  in  the  nose,  when  it  is  known  as  glanders,  and 
under  the  skin,  when  it  is  called  farcy. 

Cause. — It  is  due  to  a  specific  bacillus — Bacillus  mallei.  The 
organism  resembles  the  tubercle  bacillus,  though  somewhat  shorter 
and  thicker.  The  disease  is  communicated  by  the  discharge  from 
an  infected  animal  to  an  abraded  skin  or  mucous  surface;  it  may  also 
be  caused  by  the  inhalation  of  the  dried  mucus.  Contagious. 
Incubation  from  three  to  five  days. 

Pathological  Anatomy. — Nodules,  consisting  of  aggregations  of 
round  cells  of  lymphoid  or  polymorphonuclear  type,  which  have  a 
strong  tendency  to  suppurative  or  necrotic  softening.  In  man  the 
nodules  are  usually  small  and  consist  of  lymphoid  and  endothelial 
cells,  within  and  between  which  the  bacilli  are  to  be  found.  The 
floor  and  edges  of  the  ulcers  (softened  nodules)  are  irregular  and 
yellowish,  discharging  more  or  less  purulent  matter.  The  nodules 
develop  particularly  in  the  nares,  the  skin,  and  muscles;  but  internal 
organs  (as  lungs,  liver,  spleen,  kidneys,  stomach,  nervous  system, 
and  bones)  may  be  invaded.  The  lymphatic  glands  of  the  neck  and 
elsewhere  enlarge  and  may  suppurate. 

Symptoms. — There  is  an  acute  and  a  chronic  form  of  glanders. 

Acute  Glanders. — Redness  and  swelling  of  the  nasal  mucous  mem- 
brane with  burning  and  dryness,  followed  by  the  development  of  the 
nodules,  which  rapidly  break  down  and  discharge  a  fetid  hemorrhagic 
or  muco-pus.  Soon  there  develop  headache,  painful  deglutition, 
cough,  fever,  prostration,  and  typhoid  symptoms,  terminating 
eventually  in  death. 

Chronic  glanders  is  rare  and  is  difficult  to  recognize ;  it  is  generally 
mistaken  for  a  chronic  coryza. 

Acute  farcy,  or  glanders  of  the  skin,  consists  of  nodular  sweUings 
with  subsequent  ulcers  and  discharge  of  a  fetid  hemorrhagic  pus  on 
the  skin.     Papules,  becoming  pustules,  followed  by  ulceration,  occur 


88  rOOT   AND   MOUTH   DISEASE 

in  the  neighborhood  of  the  nodules.  The  lymphatic  glands  and 
vessels  are  involved,  and  the  glands  may  suppurate,  being  then 
called  ''farcy  buds";  the  nose  is  not  affected.  Prostration  and  ty- 
phoid symptoms  rapidly  develop.  The  bacilli  have  been  found  in 
the  urine,  both  in  man  and  animals. 

In  chronic  farcy,  the  development,  course,  and  symptoms  are  all 
of  less  severity. 

Diagnosis. — The  certainty  of  diagnosis  is  made  possible  only  by 
making  cultures.  Inoculation  with  mallein  may  be  tried;  it  causes 
a  rise  of  temperature  in  affected  cases. 

Prognosis. — Acute  variety,  fatal.  Chronic  variety,  if  early  diag- 
nosed, about  50  per  cent,  may  recover. 

Treatment. — Palliative  and  surgical  means  may  be  tried  for  the 
lesions.  Sometimes  inunctions  of  mercury,  and  internal  administra- 
tion of  potassium  iodide,  are  of  service.  Mallein  has  been  tried  in 
animals  with  variable  success. 

FOOT  AND  MOUTH  DISEASE 

Synonyms. — Epidemic  stomatitis;  aphthous  fever. 

Definition. — An  acute  infectious  disease  of  the  lower  animals, 
communicable  to  man  and  characterized  principally  by  an  eruption 
of  vesicles  and  ulcers  on  the  mucous  membrane  of  the  mouth  and  on 
the  skin  between  the  toes. 

Etiology. — It  is  supposed  to  be  caused  by  a  microorganism  not 
yet  determined.  It  is  chiefly  contracted  by  milkers  and  those  who 
work  with  diseased  cattle;  but  milk,  butter,  and  cheese  are  capable 
of  communicating  the  disease  to  man. 

S5rmptoms. — The  incubation  period  varies  from  three  to  five  days 
and  the  disease  is  ushered  in  with  slight  constitutional  reaction. 
The  characteristic  vesicles  then  appear,  attended  with  swelHng  and 
sensations  of  heat  and  burning.  Salivation  is  profuse.  The  erup- 
tion appears  between  the  toes  and  fingers  at  the  same  time,  and  may 
extend  over  the  entire  body. 

Prognosis. — In  man  recovery  is  the  rule,  except  in  the  case  of 
very  young  and  weak  children  who  are  constantly  exposed  to  the 
affection. 

Treatment. — This  is  largely  prophylactic.  Cleanliness  of  both 
man  and  beast  will  accomplish  a  great  deal  in  preventing  and  curing 
the  disease;  the  milk  should  be  boiled.     Mild  antiseptic  mouth 


SYPHILIS  89 

washes  containing  borax,  potassium  chlorate,  etc.,  should  be  em- 
ployed. 

SYPHILIS 

Synon3mis. — Lues;  the  pox. 

Definition. — An  infective  disease,  caused  by  the  Treponema  palli- 
dum, propagated  by  inoculation  from  an  infected  person  {acquired 
syphilis)  or  by  hereditary  transmission  {congenital  syphilis). 

There  are  three  stages:  (i)  The  primary,  characterized  by  a  hard 
chancre  at  the  site  of  inoculation.  (2)  The  secondary,  characterized 
by  lesions  of  the  skin  and  mucous  membranes.  (3)  The  tertiary, 
characterized  by  gummata  in  any  part  of  the  body. 

Cause. — The  Treponema  pallidum  (also  called  Spirochceta  pallida), 
a  protozoan  parasite.  This  is  a  very  delicate,  actively  motile,  long, 
spiral,  thread-like  organism,  varying  in  length  from  4  to  20  fjL  and 
tapering  at  each  end  to  a  sharp  point.  It  has  been  demonstrated 
in  syphilitic  lesions  in  all  stages  of  the  acquired  disease,  and  is  very 
constantly  found  in  the  blood  and  tissues  of  infants  suffering  from 
congenital  syphilis. 

Modes  of  Infection. — {a)  Acquired  Syphilis. — In  the  large  majority 
of  cases,  infection  occurs  during  sexual  connection,  and  the  primary 
sore  appears  on  the  genital  organs ;  but  extra-genital  sores  sometimes 
occur,  on  the  lips,  face,  tonsils,  fingers,  nipple.  Infection  may  also 
occur  through  the  use  of  contaminated  instruments  or  drinking 
vessels;  and  physicians,  accoucheurs,  and  nurses  may  become  infected 
while  making  necessary  examinations  or  dressings. 

{b)  Congenital  Syphilis. — Hereditary  transmission  of  the  disease 
may  be  (i)  from  the  father,  the  mother  being  healthy;  this  is  known 
as  sperm  inheritance:  (2)  from  the  mother,  the  father  being  healthy; 
this  is  known  as  germ  inheritance:  or  (3)  through  the  placenta,  an 
originally  healthy  mother  having  become  infected  during  pregnancy, 
in  which  case  the  child  may  be,  but  is  not  necessarily,  born  syphilitic. 

When  a  syphilitic  child  is  born  of  a  mother  who  herself  shows  no 
sign  of  the  disease,  the  mother  is  immune  to  syphilis;  she  may 
suckle  the  child  even  when  it  has  syphilitic  sores  on  the  mouth  and 
yet  escape  infection;  whereas  a  wet  nurse  suckling  the  same 
child,  will  contract  the  disease.  This  is  Colles '  Law;  and  the  probable 
explanation  is  that  the  mother  has  received,  during  pregnancy,  a 
protective  inoculation. 

Qne  attack  generally  confers  immunity. 


90  ACQUIRED   SYPHILIS 

ACQUIRED    SYPHILIS 

Incubation  Period. — The  time  between  exposure  to  infection  and 
the  appearance  of  the  primary  sore  is  from  ten  days  to  eight  weeks, 
usually  about  three  or  four  weeks. 

Morbid  Anatomy. — The  essential  features  of  all  syphilitic  lesions 
are  the  same:  (i)  An  infiltration  of  the  infected  tissue  with  small 
round  cells  of  lymphoid  type;  (2)  proliferation  of  connective-tissue 
cells,  forming  a  granulation  tissue;  (3)  sometimes,  giant  cells;  (4) 
an  endarteritis  obliterans,  whereby  the  inner  coat  of  the  small 
arteries  is  thickened,  and  the  lumen  narrowed.  The  fate  of  the 
granulation  tissue  depends  upon  various  factors — the  tissue  in  which 
it  is  lodged,  the  moisture  or  dryness  of  the  part,  the  age  of  the  patient, 
the  concentration  or  diffuseness  of  the  original  infiltration,  and  the 
amount  of  obliteration  of  the  adjacent  arterial  field. 

In  the  primary  stage,  the  lesion  is  a  hard  chancre  at  the  site  of 
inoculation.  Beginning  as  a  papule  of  granulation  tissue,  it  ulcerates, 
forming  a  sore  with  a  very  much  indurated  base.  The  granulation 
tissue  does  not  go  on  to  form  fibrous  tissue  and  so,  after  healing, 
practically  no  cicatrization  occurs  or  scar  remains.  The  glands  in 
the  lymphatic  field  of  the  affected  organ  become  enlarged,  hard, 
and  shotty. 

In  the  secondary  stage,  the  syphilitic  poison  attacks  skin  and  mucous 
membranes.  The  chief  skin  lesions  are  roseola,  papules,  pustules, 
scales,  and  rupia  in  the  late  secondary  period.  Where  the  skin 
is  moist,  as  in  the  perineum,  vulva,  axiUse,  and  between  the  toes, 
soft  warty  growths  of  granulation  tissue  form,  which  are  called  con- 
dylomata. The  lesions  found  in  the  mucous  membranes  are  pharyn- 
gitis and  mucous  patches.  Mucous  patches  are  shallow  ulcers  which 
occur  in  the  mouth,  tongue,  uvula,  tonsil,  and  soft  palate.  The 
lymphatic  glands  throughout  the  body  are  usually  enlarged;  the  hair 
is  thinned;  periostitis,  with  formation  of  nodes,  synovitis,  iritis,  some- 
times epididymitis,  may  occur.  There  is  often  a  pronounced  anemia, 
and  sometimes  lesions  of  the  central  nervous  system. 

In  the  tertiary  stage,  the  same  characteristic  infiltration  of  the  tis- 
sues with  small  round  cells  occurs.  If  this  process  is  concentrated,  a 
gumma  is  formed;  if  it  is  diffuse,  fibrous  tissue  is  produced  which, 
by  its  contraction,  destroys  the  structure  of  the  organ  in  which  it 
occurs,  the  process  being  known  as  sclerosis.  Gummata  may  occur 
in  any  part  of  the  body,  and  vary  in  size  from  microscopic  objects 


ACQUIRED   SYPHILIS  9 1 

to  large  firm  tumors,  i  to  3  inches  in  diameter.  On  cross-section, 
a  gumma  has  a  grayish-white  homogenous  appearance,  with  a  firm 
caseous  center  and  a  translucent  fibrous  periphery.  An  accompany- 
ing endarteritis  obliterans,  by  gradually  lessening  the  blood  supply 
explains  the  coagulation  necrosis  of  the  central  portion.  Micro- 
scopically, a  gumma  consists  of  masses  of  small  round  cells  and  pro- 
liferated connective-tissue  cells  and  sometimes  giant  cells  and  eipthe- 
lioid  cells.  The  most  frequent  sites  of  gummata  are  periosteum  and 
bone,  liver  and  brain.  If  gummata  are  situated  in  mucous  mem- 
brane {e.g.,  the  larynx  and  rectum)  or  in  tissues  near  to  a  skin  surface, 
ulceration  and  great  destructive  change  may  occur,  and  later, 
cicatrization  and  great  deformity.  In  an  internal  organ,  under 
appropriate  treatment,  a  gumma  may  be  absorbed,  leaving  only  a 
cicatrix.  A  long,  slow  syphilitic  infiltration  of  bone  may  result,  not 
in  gumma,  but  in  osteosclerosis,  whereby  the  bone  becomes  dense 
and  hard  as  ivory,  with  almost  complete  obliteration  of  the  medullary 
cavity.  Amyloid  degeneration  may  occur  in  liver,  spleen,  kidneys 
and  small  intestine.  The  skin  affection  of  this  stage,  known  as 
tertiary  syphilides,  tend  to  affect  the  deeper  layers  of  the  skin  and 
cause  ulceration,  leaving  scars  after  they  heal;  the  most  characteristic 
is  rupia. 

Parasyphilitic  diseases,  of  which  locomotor  ataxia,  dementia 
paralytica,  and  aneurysm  are  examples,  are  diseases  which,  though 
not  directly  syphilitic,  are  produced  in  some  way  by  the  poison  of 
syphilis. 

Symptoms. — Primary  Stage. — This  stage  begins  with  the  appear- 
ance of  the  primary  sore,  and  ends  with  the  onset  of  the  skin  lesions 
and  constitutional  symptoms,  the  usual  duration  being  six  to  twelve 
weeks.  About  a  month  after  inoculation,  a  red  papule  appears  at 
the  seat  of  invasion.  The  papule  enlarges  and  breaks  down,  form- 
ing an  ulcer  with  a  very  hard  base,  feeling  to  the  touch  Uke  a  button 
felt  through  a  thin  layer  of  clothing.  The  glands  in  the  correspond- 
ing lymph  field  are  enlarged,  hard  and  shotty,  but  do  not  suppurate 
unless  there  is  a  mixed  infection  with  pyogenic  organisms  or  the 
bacillus  of  chancroid.  The  patient  feels  well  and  has  no  other 
symptoms. 

Secondary  Stage. — This  stage  usually  begins  within  twelve  weeks 
from  the  appearance  of  the  primary  sore,  and  lasts  about  two  years, 
if  treatment  is  omitted.  The  first  symptoms  are  malaise  and  a  fever, 
usually   mild,    sometimes   pronounced.     The   face   becomes   paler, 


92  ACQUIRED    SYPHILIS 

and  the  complexion  muddy;  and  examination  of  the  blood  shows 
some  anemia.  But  the  patient  usually  seeks  medical  advice  because 
of  the  skin  rashes.  The  first  to  appear  is  a  roseola,  affecting  the 
trunk  and  flexor  surfaces  of  the  arms ;  it  is  often  a  mere  dirty  reddish- 
brown  erythema,  which  disappears  in  a  week  or  two,  generally  to 
-  appear  later.  The  next  to  appear  is  a  squamous  or  scaly  rash  resem- 
bling, but  quite  distinct  from,  psoriasis,  beginning  on  the  forehead 
and  spreading  to  the  trunk  and  limbs.  A  papular  eruption  resem- 
bling acne,  may  occur  on  the  face  and  trunk;  and,  less  frequently,  the 
rash  may  be  pustular.  In  the  late  secondary  as  well  as  in  the  ter- 
tiary stage  the  limpet-shaped  scabs  of  rupia  may  be  seen  in  rare 
instances.  The  patient  complains  of  sore  throat.  On  examination, 
pharyngitis  and  enlarged  tonsils  are  found,  and  at  the  same  time 
mucous  patches  may  be  seen  on  the  tonsils,  buccal  mucous  membrane, 
tongue  and  lips.  The  hair  frequently  becomes  thinned,  or  falls  out 
in  patches  (alopecia),  and  inflammation  of  the  nail  matrix  may  occur 
(onychia) .  In  regions  which  are  always  moist  such  as  the  perineum, 
vulva,  axillae,  and  between  the  toes,  condylomata  may  be  found, 
two  patches  of  these  gray  warty  growths  often  forming  opposite  to 
each  other  where  the  skin  surfaces  lie  in  apposition.  The  lymphatic 
glands  throughout  the  body  are  usually  enlarged  and  hard.  Glands 
which  are  usually  non-apparent  become  evident,  for  example,  the 
posterior  cervical  chain  and  the  epitrochlear  gland. 

Iritis  is  common  and  is  recognized  by  the  photophobia,  pain, 
lacrymation,  ciliary  congestion,  irregular  and  sluggish  pupil,  and 
little  points  of  lymph  exudation  on  the  iris.  The  iris  may  be  adherent 
to  the  cornea  or  lens.  A  drop  of  i  per  cent,  solution  of  atropine 
sulphate  in  the  eye  quickly  reveals  any  irregularity  of  the  pupil  or 
adhesion  of  the  iris.  The  patient  complains  of  pains  in  the  bones 
and  headaches,  especially  at  night.  The  cause  of  this  is  periostitis, 
which  may  end  in  the  formation  of  nodes.  A  mild  synovitis 
may  occur,  and  occasionally  epididymitis.  A  rare  symptom  is  a 
choroido-retinitis,  in  which  case  the  complaint  is  that  vision  is 
defective,  especially  at  night,  and  that  objects  appear  smaller  or 
distorted. 

All  these  changes  may  be  recovered  from  and  no  trace  of  the  dis- 
ease be  left.  If  the  patient,  as  is  often  the  case,  thinks  himself 
entirely  well  and  gives  up  treatment,  he  is  apt  to  get  "reminders,'* 
in  the  shape  of  irritable  throat  which  compels  him  to  give  up  smoking, 
little  inflammations  and  cracks  about  the  nails  and  toes  which  refuse 


ACQUIRED    SYPHILIS  93 

to  heal,  and  skin  eruptions,  usually  of  a  papular  form  and  tending 
to  ulcerate. 

Tertiary  Stage. — The  symptoms  of  this  stage  may  follow  imme- 
diately upon  those  of  the  secondary  stage,  or  may  be  postponed,  it 
may  be,  for  many  years.  Untreated,  tertiary  syphilis  remains  with 
the  patient  all  his  life.  The  disease  process  is  less  generalized  than 
in  the  secondary  stage;  its  manifestations  are  more  localized.  Any 
organ  in  the  body  may  be  affected,  hence  the  symptoms  are  most' 
diverse.  Skin  and  subcutaneous  gummata  are  very  common. 
Beginning  as  a  swelling,  they  break  down  by  a  process  of  coagulation 
necrosis,  and  form  an  ulcer  of  rounded  shape,  with  sharply  cut  edges, 
and  a  base  the  appearance  of  which  has  been  compared  to  "wash 
leather. "  They  disappear  under  appropriate  treatment,  leaving 
a  thin  white  scar,  surrounded  often  by  a  pigmented  ring,  and  do  not 
tend  to  recur  locally.  Gummata  occur  also  on  mucous  surfaces, 
the  chief  sites  being  the  mouth,  tongue,  and  tonsils,  the  larynx  and 
pharynx,  and  the  rectum.  The  cicatrization  that  follows  the  healing 
of  a  gumma  may  cause  stenosis  of  natural  passages,  notably  the 
rectum  and  the  larynx.  Among  the  most  frequent  sites  of  gummat- 
ous formation  are  the  bones  and  periosteum.  The  bones  chiefly  af- 
fected are  the  frontal  and  nasal  bones,  the  clavicle,  sternum,  and  tibia. 
The  patient  complains  of  ''rheumatic"  pains,  worse  at  night;  a 
tender  ovoid  swelling  forms,  called  a  periosteal  node;  the  surrounding 
bone  is  felt  to  be  thickened  and  hard;  the  bone  underneath  under- 
goes either  caries  (microscopic  death)  or  necrosis  (macroscopic  death) ; 
the  skin  over  it  ulcerates,  and  large  sequestra  of  bone  may  come  away. 
The  destruction  of  the  skin  of  the  forehead  and  part  of  the  frontal 
bone  causes,  after  healing,  the  white  cicatrix  known  as  the  ^^  corona 
Veneris. ''  Necrosis  of  the  nasal  bones,  the  sequestra  of  which  are 
discharged  by  the  nasal  passages,  leads  to  the  characteristic  and  well- 
known  depression  of  the  bridge  of  the  nose.  Necrosis  of  the  hard 
palate  results  in  perforation  of  that  structure,  and  consequent  escape 
of  food  into  the  nose. 

In  the  brain,  gummata,  with  or  without  surrounding  meningeal 
inflammation,  arteritis  of  the  inner  or  outer  coats,  and  sclerosis  may 
cause  an  infinity  of  symptoms  depending  for  their  character  on  the 
location  of  the  lesion.  Thus,  if  the  psychic  area  is  chiefly  aft'ected, 
the  patient  may  show  symptoms  like  those  of  brain  "softening," 
headache,  childishness,  alteration  of  character,  loss  of  memory  and, 
it  may  be,  delirium.     If  the  motor  tract  is  involved,  there  may  be 


94  ACQUIRED   SYPHILIS 

hemiplegia.  Pressure  on  the  cranial  nerves  at  the  base  of  the  brain 
may  cause  paralysis  of  their  function.  A  gumma  situated  near  the 
surface  of  the  brain  may  cause  epileptic  seizures,  because  of  the  irrita- 
tion of  the  cortex.  In  other  cases,  the  symptoms  are  those  of  brain 
tumor,  headache,  vomiting,  optic  neuritis  and  convulsions.  Syphi- 
litic disease  of  the  arteries  may  lead,  by  rupture,  to  cerebral  hemor- 
rhage, or,  by  diminution  of  their  caliber,  to  thrombosis  or  softening, 
with  their  attendant  symptoms.  Generally,  as  a  late  manifestation, 
a  diffuse  sclerosis  of  the  brain  may  occur,  which  results  in  dementia 
paralytica,  characterized  by  irritability,  change  of  character,  delu- 
sions of  grandeur,  intense  egoism,  Argyll-Robertson  pupil,  optic 
atrophy,  and  increased  knee-jerk. 

In  the  spinal  cord,  syphilis  may  result  in  gumma,  meningitis, 
myelitis,  or  sclerosis.  Sclerosis  is  a  late  manifestation,  the  most 
common  form  being  locomotor  ataxia,  in  which  the  affected  parts 
are  the  spinal  gangHa  and  the  posterior  columns. 

Syphilis  of  the  liver  may  show  itself:  (i)  As  a  cirrhosis,  with  slight 
jaundice,  fever,  obstruction  of  the  portal  circulation  and  ascites; 
(2)  as  a  gumma,  with  pain,  Hver  enlargement,  and  an  irregular  tumor 
mass,  simulating  malignant  disease;  or  (3)  as  amyloid  degeneration, 
in  association  with  similar  change  in  the  spleen,  kidneys,  and  mucous 
membrane  of  the  small  intestine,  so  that  the  clinical  picture  is  one 
of  anemia,  enlarged  smooth  Hver  and  spleen,  the  passage  of  large 
quantities  of  pale  urine  of  low  specific  gravity,  1005  to  loio,  contain- 
ing albumin  and  casts,  with  sometimes  diarrhea  and  finally  dropsy. 

The  circulatory  system  may  be  profoundly  affected.  Syphilitic 
arteriosclerosis  presents  the  same  symptoms  as  arteriosclerosis  of 
other  origin;  and  aneurysm  is  a  frequent  late  result  of  the  syphilitic 
virus.  The  heart  may  be  affected  with  (i)  aortic  disease,  stenosis 
or  insufficiency,  due  to  an  extension  backward  of  an  aortitis,  or 
(2)  sclerosis,  resulting  in  the  extremely  varied  symptoms  of  cardio- 
sclerosis, or  (3)  gumma.  If  a  gumma  or  sclerosis  affects  the  auriculo- 
ventricular  bundle  of  His,  the  condition  of  heart-block  appears, 
in  which  auricular  impulses  are  blocked  from  time  to  time  on  their 
way  to  the  ventricles,  and  the  auriculo-ventricular  rhythm  is  altered 
from  the  normal  1:1  to  2:1  or  3:1.  Tertiary  syphilis  of  the  tes- 
ticle is  recognized  as  a  hard,  painless,  tumor  of  the  body  of  the 
organ,  unhke  tuberculosis  which  attacks  the  epididymis  with  early 
loss  of  testicular  sensation,  and  with  no  tendency  to  break  down  or 
suppurate. 


ACQUIRED    SYPHILIS  95 

The  usual  result  of  repeated  conception  in  a  syphilitic  woman  is 
that,  at  first,  abortion  occurs  in  the  early  months  of  pregnancy;  but 
in  subsequent  pregnancies  the  fetus  is  carried  longer,  until,  at  length, 
a  full-term  dead  child  or  a  premature  living  child,  bearing  the  marks 
of  the  disease,  is  brought  forth ;  then  mature  children  are  born  which 
show  evidence  of  the  disease  only  after  some  weeks  have  elapsed; 
finally,  healthy  infants,  remaining  free  from  all  taint  of  syphilis 
come  into  the  world.  This  sequence  of  events,  however,  may  be 
most  favorably  altered  by  treatment. 

Diagnosis. — (a)  Clinical. — The  primary  sore  is  diagnosed  from  the 
soft  sore  (chancroid)  by  its  hardness,  the  shotty  character  of  the 
lymphatic  glands  and  the  fact  that  they  do  not  tend  to  suppurate, 
and  by  finding  the  Treponema  pallidum.  Herpes  progenitalis  is 
vesicular  not  papular,  and  disappears  in  a  few  days. 

The  skin  eruptions  of  syphilis  have  certain  characteristics  which, 
apart  from  the  history,  are  useful  guides:  {a)  They  are  granuloma- 
tous affections  and  hence  there  is  always  a  feeling  of  something  under 
the  skin  as  well  as  on  it.  (&)  They  are  polymorphous — several 
varieties  appearing  on  the  skin  at  the  same  time,  (c)  Syphilis 
being  a  blood  infection,  the  skin  eruptions  tend  to  be  symmetrical. 
{d)  They  have  a  color  resembling  copper  or  raw  ham.  {e)  They 
are  often  serpiginous.  (/)  There  is  a  notable  absence  of  pain  and 
itching,  {g)  They  tend  to  affect  flexor  aspects  (unlike  psoriasis), 
front  and  back  of  the  trunk,  and  forehead,  {h)  The  scars  of 
rupia  and  ulcers  are  thin,  white,  and  round,  with  a  pigmented 
margin. 

Syphilitic  manifestations  are  rarely  found  singly,  and  a  full  physi- 
cal examination  will  usually  discover  some  other  sign.  In  the 
secondary  stage  mucous  patches  must  be  diagnosed  from  dental 
ulcers,  follicular  tonsillitis,  and  smoker's  ulcers;  but  the  history, 
or  the  primary  sore,  or  the  enlarged  lymphatic  glands,  or  the  sore 
throat,  or  the  "moth-eaten"  hair,  or  a  skin  rash,  will  generally  give 
the  clue. 

In  women,  the  history  of  frequent  miscarriages  or  dead-born 
children  is  strong  evidence  in  favor  of  syphilis. 

Gummata  may  have  to  be  distinguished  from  tumors,  innocent 
and  malignant.  Innocent  tumors  are  well-defined,  often  lobulated, 
and  are  generally  single.  Gummata  are  ill-defined,  never  lobulated, 
and  are  frequently  multiple.  Cancer  usually  occurs  singly,  and  in 
patients  who  are  past  middle  life;  while  gummata  are  most  frequent 


96  ACQUIRED    SYPHILIS 

between  the  ages  of  twenty-five  and  thirty-five.  In  a  doubtful  case, 
the  history,  the  microscope,  and  the  result  of  treatment  usually 
clear  up  the  point. 

(b)  Serum  Diagnosis. — The  Wassermann  blood-serum  reaction, 
though  not  pathognomonic,  is  highly  characteristic  of  syphilis.  It 
is  to  be  regarded  as  the  necessary  second  symptom  in  a  doubtful 
case.  Like  other  symptoms  it  is  only  of  value  if  it  is  present;  its 
absence  has  no  significance.  It  usually  appears  in  the  third  week 
after  exposure,  and  its  meaning  is  that  the  patient  is  already  suffering 
•from  generalized  syphilis.  In  some  cases  of  latent  and  tertiary 
syphilis  the  reaction  may  fail  to  be  positive  in  the  blood-serum  but 
may  be  obtained  in  the  cerebrospinal  fluid.  Noguchi  has  drawn 
attention  to  the  Luetin  intradermic  test.  Its  special  sphere  is 
tertiary,  latent,  and  hereditary  syphihs,  where  the  Wassermann 
reaction  is  least  reliable.  It  can  be  applied  by  the  general  practi- 
tioner, while  the  Wassermann  test  requires  a  laboratory,  and  a  reliable 
one  at  that. 

(c)  Therapeutic  Test. — In  case  of  doubt,  an  obscure  abdominal 
tumor,  an  obstinate  skin  rash,  a  suspicious  fissure  of  the  tongue  may 
disappear  under  antisyphilitic  treatment,  leaving  the  presumption 
that  the  case  is  one  of  syphilis. 

Prognosis. — If  the  patient  comes  under  treatment  early  and  if 
treatment  is  thorough,  the  prognosis  is  good.  If  there  is  an  idio- 
syncrasy to  mercury  and  iodides  which  prevents  proper  treatment, 
the  outlook  is  less  favorable.  Syphilis  plus  tuberculosis  or  alcohol- 
ism is  an  exceedingly  bad  combination. 

In  the  secondary  stage  death  may  occur,  rarely,  from  edema  ol 
the  glottis;  in  the  tertiary  stage  from  disease  of  the  brain,  spinal 
cord,  liver  or  larynx.  Ninety  per  cent,  of  cases,  under  thorough 
treatment,  escape  tertiary  lesions. 

Prophylaxis. — The  prophylaxis  of  syphilis  in  the  community  at 
large  is  a  vexed  question.  After  exposure,  the  liberal  use  of  soap 
and  water,  followed  by  the  thorough  inunction  of  a  30  per  cent, 
calomel  ointment  within  an  hour  of  infection  will,  it  is  asserted, 
prevent  the  development  of  the  disease. 

Treatment. — Syphilis  is  most  amenable  to  treatment.  Arsenic 
is  used  to  get  the  disease  quickly  under  control ;  mercury  to  extermi- 
nate the  Treponema;  and  iodides  to  remove  the  syphilitic  deposits 
from  the  tissues. 

Arseno-benzol,  or  salvarsan,  "606,"  is  injected  intravenously  or 


ACQUIRED    SYPHILIS 


97 


intramuscularly,  in  a  dose  of  0.6  gm.  for  a  man,  0.5  for  a  woman, 
and  repeated  twice  at  intervals  of  a  fortnight.  As  a  rule,  under  its 
influence,  primary  and  secondary  lesions  rapidly  heal,  the  patient 
is  made  more  comfortable  and,  what  is  very  important,  he  is  rendered 
much  less  infectious  to  others.  It  is  a  dangerous  drug  and  must  be 
used  with  care.  It  has  caused  optic  neuritis  and  death;  and  is  abso- 
lutely contraindicated  where  there  is  disease  of  the  cardiovascular, 
renal  or  central  nervous  systems.  Arseno-benzol  does  not  ''cure" 
syphilis;  mercury  does.  The  administration  of  mercury  must  begin 
at  once  and  must  be  kept  up  for  three  years  under  the  ''continuous 
intermittent  plan."  The  intramuscular  method  is  the  best,  for  it 
keeps  the  treatment  in  the  hands  of  the  physician  and  ensures  its 
being  carried  out.  An  insoluble  form  of  mercury  is  chosen,  for  it 
forms  a  depot  in  the  muscles  from  which  the  drug  is  gradually  and 
regularly  distributed  to  the  tissues.  Calomel  and  the  basic  salicy- 
late of  mercury  are  the  forms  most  commonly  used.  The  preparation 
most  in  favor  at  present  is  a  suspension  of  20  per  cent,  basic  salicy- 
late of  mercury  in  a  mineral  oil  known  commercially  as  albolene; 
5  drops  (the  equivalent  of  i  gr.  of  the  drug)  is  an  average  dose.  An 
ordinary  all-glass  hypodermic  syringe  may  be  used,  provided  the 
needle  is  one  and  a  half  inches  long,  with  a  lumen  large  enough  to 
allow  the  passage  of  the  suspension.  The  injection  is  given  deep 
into  the  gluteal  muscles.  The  initial  dose  should  be  small,  2  to  3 
drops,  to  test  the  patient's  susceptibility;  and  subsequent  doses 
should  be  regulated  by  the  patient's  general  condition  and  symptoms. 
Stout  subjects  receive  more  than  those  who  are  thin;  middle-aged 
more  than  the  young  and  the  aged.  As  treatment  proceeds,  patients 
who  are  weak  or  debilitated  receive  smaller  doses;  on  the  other  hand, 
obstinate  or  relapsing  lesions  call  for  an  increase  of  the  dose.  Under 
ordinary  circumstances  the  amount  of  mercury  is  decreased  as  time 
goes  on,  and  the  interval  between  doses  is  increased.  It  is  convenient 
to  tabulate  an  average  treatment: 


Months 

No.   of  injections 

Average    dose        Average^  ^mterval 

First  ■ 
Year 

Second 
Year 
Third  Y 

1st  to  6th 
7th  to  8th 
gth  to  12th 
1st  to  5th 
6th  to  7th 
8th  to  1 2th 
mr. — Same  as 

26 
omit  treatment,  but 

10-15 

10 
omit  treatment,  but 
1                  10 
second  year. 
1 

5  drops  ( =  I  gr.) 
keep  patient  unde 
4  drops   (  =  f5gr.) 
3  drops  (  =  ^5gr.) 
keep  patient  unde 
3  drops  i  =  H  gr) 

7 
;r  observation 
10 

iv  observation 
14 

gS  ACQUIRED   SYPHILIS 

It  is  now  taught  that  iodides  should  be  given  in  the  second  year, 
so  as  to  remove  the  very  beginnings  of  syphilitic  deposit.  Iodide  of 
potassium  or  of  sodium  is  most  conveniently  administered  in  saturated 
solution  (which  for  practical  purposes  may  be  considered  as  loo  per 
cent.).  Thus  lo  drops  contains  approximately  lo  gr.  of  the  drug, 
and  this  is  the  usual  dose  during  the  second  year.  The  prescription , 
would  be  as  follows: 

I^.     Saturated  solution  of  Sodium 

Iodide §iij  90    c.c. 

SiG. — Take  10  drops  in  a  small  cupful  of  milk,  three  times  a  day, 
after  meals. 

During  the  third  year  this  dose  is  increased  to  15  or  20  drops;  and  in 
the  presence  of  obstinate  symptoms,  the  drug  may  need  to  be  used 
in  enormous  doses,  30,  60,  or  even  more  grains,  thrice  daily.  If 
these  large  doses  are  badly  borne  by  the  stomach  they  may  be  given 
by  the  rectum. 

If  for  any  reason  intramuscular  injections  of  mercury  cannot  be 
given,  the  drug  may  be  administered  by  mouth,  in  various  forms, 
e.g.,  the  Protiodide  {Hydrargyri  lodidum  Flavum)  in  doses  of  gr.  }/^ 
to  }'2j  and  Mercury  with  Chalk  {Hydrargyrum  cum  Creta)  in  doses 
of  I  to  3  gr.  As  diarrhea  is  apt  to  occur  during  the  administration, 
it  is  advisable  to  add  opium,  thus: 

I^.     Hydrarg.  iodid.  flav gr.  xx  1.3  gm. 

Pulv.  opii gr.  XX  1.3  gm. 

M. — Ft.  in  pil.  no.  c. 

S. — One  pill,  three  times  a  day,  after  meals. 

Or— 

I^.     Hydrarg.  cum  creta gr.  ij  0.12  gm. 

Pulv.  ipecac  et  opii *  gr.  ij  o.  12  gm. 

M.  S. — In  pill,  three  times  a  day,  after  meals. 

The  daily  number  of  pills  should  be  increased  by  one  pill  a  day,  until 
the  patient  shows  signs  of  salivation.  Treatment  is  then  stopped 
until  the  symptoms  of  mercurialization  disappear;  then  it  should  be 
resumed  with  a  regular  dose  equivalent  to  half  of  that  which  caused 
salivation.  With  intervals  of  omission,  this  treatment  should 
continue  for  three  years.  When  iodide  has  to  be  added,  it  is  often 
convenient  to  use  the  drugs  in  combination  (the  so-called  '^  Mixed 
Treatment'^)  as  follows: 

\ 


ACQUIRED   SYPHILIS  99 

I^.     Hydrarg.  chloridi  corrosivi  .   gr.  ^i  0.02  gm. 

Sodii  vel  Potassii  iodidi gr.  Ixxx  5.0    gm. 

Syrupi  zingiberis lUlxxx  5 .  o    c.c. 

Aquae q.  s.  ad   giv  120.0    c.c. 

M.  S. — One  desertspoonful,  thrice  daily,  after  meals. 

Overdosage  or  idiosyncrasy  in  the  case  of  these  two  drugs  may  cause 
mercurialism  or  iodism.  The  symptoms  of  mercurialism  are  saliva- 
tion; swollen,  spongy,  bleeding  gums;  loosening  of  the  teeth;  offensive 
breath;  colic;  and  diarrhea.  Treatment  consists  in  stopping  the  drug, 
giving  saline  laxatives,  and  an  astringent  mouth  wash.  TYiq  symp- 
toms of  iodism  are  coryza,  swelling  of  the  nasal  mucous  membrane, 
headache,  general  malaise,  and  acne.  Treatment  consists  in  doubling 
the  dose  of  iodide  and  adding  4  drops  of  Fowler's  solution  (Liquor 
Potassii  Arsenitis)  to  each  dose.  If,  however,  pronounced  anorexia 
and  vomiting  ensue,  the  drug  must  be  stopped.  Iodide  should 
always  be  given  after  meals,  and  in  milk. 

Treatment  by  inunction  of  Blue  Mass  (Massa  Eydrargyri)  is 
sometimes  used,  but  gives  good  results  only  when  administered  by 
skilled  rubbers. 

Treatment  by  fumigation  is  unsatisfactory. 

The  patient  must,  from  the  very  beginning,  give  up  tobacco  and 
alcohol,  have  his  teeth  attended  to  by  a  competent  dentist,  and  use 
a  mild  antiseptic  mouth  wash.  He  must  be  told  that  he  is  infectious; 
he  must  use  separate  eating,  drinking,  and  toilet  utensils  during  the 
entire  first  year,  and  as  long  as  he  has  open  sores  on  the  skin,  lips 
or  mouth.  He  must  be  told  that  his  semen  is  infectious  and  appro- 
priate advice  must  be  given. 

The  patient  is  considered  cured  when  three  conditions  are  satisfied : 
(i)  A  three  years'  course  of  treatment  similar  to  that  just  described; 
(2)  a  fourth  year,  without  treatment  and  without  symptoms;  (3) 
a  negative  Wassermann  serum  reaction  on  at  least  three  occa- 
sions, at  different  periods  of  the  fourth  year.  Such  a  patient  may  be 
allowed  to  marry. 

Local  Treatment. — In  the  treatment  of  any  local  evidence  of 
syphilis  it  is  necessary  to  begin  thorough  general  treatment  at  once. 

The  ordinary  chancre  is  treated  by  washing  three  times  a  day  with 
Black  Wash  (Calomel  5j,  Aq.  calcis,  i  pint),  and  dusting  with  a 
powder  containing  equal  parts  of  calomel  and  starch.  If  it  is  in- 
flamed, it  must  first  be  treated  with  boric  acid  compresses.  If 
gangrene  sets  in,  the  patient^must  be  put  to  bed  and  hot  compresses 


lOO  ACQUIRED    SYPHILIS 

of  1 :  5000  of  bichloride  of  mercury  applied  on  the  part  immersed  for 
hours  daily  in  a  bath  of  hot  boric  acid  solution.  If  the  gangrene 
is  spreading  rapidly,  a  general  anesthetic  should  be  given  and  the 
edges  of  the  ulceration  destroyed  with  the  actual  cautery. 

The  Secondary  Cutaneous  Eruptions. — When  the  skin  is  unbroken, 
the  use  of  a  mercurial  soap  by  day  and  the  inunction  of  White 
Precipitate  Ointment  (Unguentum  Eydrargyri  Ammoniati)  at  night 
are  sufficient.  When  the  skin  is  broken,  e.g.,  in  pustular  and  ulcera- 
tive conditions  the  lesions  must  first  be  cleansed  with  i :  5000  bichlo- 
ride of  mercury  compresses,  followed  by  the  use  of  White  Precipi- 
tate Ointment.  Condylomata  must  be  cleansed  with  Black  Wash 
and  dusted  with  the  calomel-starch  powder  mentioned  above. 

The  secondary  lesions,  of  the  mouth  and  throat  are  treated  with  an 
antiseptic  astringent  gargle,  such  as: 

'Sf,.     Potassii  chloratis 5jss  6     gm. 

Alum,  sulphatis 5jss  6     gm. 

Glycerin 5iij  12     c.c. 

Aquae  destillatse q.  s.  ad   §viij  240  c.c. 

M.  S. — The   gargle;    i  ounce   to   be  used  mixed  with  i  ounce 
of  warm  water,  as  frequently  as  possible. 

Mucous  patches,  if  obstinate,  are  to  be  lightly  touched  with  chromic 
acid  fused  into  a  bead  on  the  point  of  a  probe. 

Lesions  of  the  vagina  are  treated  with  frequent  douches  of  i  :  10,000 
bichloride  of  mercury. 

In  iritis,  drop  into  the  eye  a  2  per  cent,  solution  of  atropine  sul- 
phate every  two  hours  if  necessary,  until  full  dilatation  is  attained, 
and  thereafter  three  times  a  day;  and  push  the  general  treatment 
vigorously. 

For  alopecia,  rub  into  the  scalp  once  daily  the  following  lotion: 

I^.     Hydrargyri  bichloridi gr.  viij  .48  gm. 

Glycerin 5ij  8.0    c.c. 

Alcohol Bij  60 . o    0,0. 

Aqu^  destillatse q.  s.  ad  giv         120.0    c.c.     M. 

In  onychia,  cleanse  with  weak  bichloride  compresses  and  use  white 
precipitate  ointment. 

For  hone  and  joint  lesions,  push  the  internal  treatment  and  use 
inunctions  of  any  mercurial  ointment. 

In  the  tertiary  stage,  the  gumma,  ii  unbroken,  is  not  to  be  opened; 


CONGENITAL    SYPHILIS  lOI 

protect  it,  use  mercurial  ointment  gently,  and  this  combined  with 
vigorous  internal  treatment  will  cause  its  absorption.  If  it  is  ulcer- 
ated, cleanse  it  with  bichloride  compresses  and  then  use  white 
precipitate  ointment  thickly  smeared  on  linen  or  cotton  cloth. 
Gummata  of  internal  organs  are  inaccessible  to  local  treatment  but 
are  very  amenable  to  the  general  treatment  which  has  been  outlined. 

CONGENITAL  SYPHILIS 

The  different  modes  of  infection  and  the  effect  of  syphilis  on  re- 
peated conceptions  have  already  been  described  (page  89). 

Morbid  Anatomy. — Here  the  syphilitic  virus  affects  young, 
growing  tissues,  and  since  its  action  is  to  increase  the  formation  of 
fibrous  tissue  especially  of  and  around  the  arteries,  the  result  is  a 
diffuse  sclerosis,  so  that  the  parenchyma  of  the  organ  suffers  in 
nutrition  and  does  not  mature  as  quickly  as  it  otherwise  would  have 
done.  Gummata  are  not  as  frequent  as  in  the  acquired  form,  and 
are  small  (miliary). 

There  is  no  primary  sore.  The  skin  may  show  the  following  rashes, 
macular,  papular,  pustular,  and  pemphigus.  Condylomata  may 
be  found  around  the  anus  and  mouth.  Onychia  and  thinning  of 
the  hair  may  occur.  Fissures  occur  round  the  mouth  which,  on 
healing,  leave  scars  called  rhagades.  Catarrh,  ulceration,  and  bone 
necrosis  may  occur  in  the  nasal  cavities,  resulting  in  depression  of 
the  bridge  of  the  nose.  Laryngitis  is  frequent.  Epiphysitis  of  the 
long  bones,  especially  the  radius  and  humerus,  may  occur,  leading 
sometimes  to  separation  of  the  epiphysis.  Periostitis,  leading  to 
thickening  of  the  bones,  is  found,  especially  round  the  anterior 
fontanelles,  where  it  forms  swellings  or  bosses,  known  as  "Parrot's 
nodes. "  Periostitis  is  also  found  on  the  phalanges,  forming  a  spindle- 
shaped  dactylitis,  and  on  the  long  bones,  especially  the  tibia,  forming 
a  spindle-shaped  swelling  or  multiple  nodes.  Craniotabes,  a  thin- 
ning of  the  bones  of  the  skull  due  to  caries,  is  attributed  by  some 
authorities  to  syphilis,  but  is  probably  in  most  cases  due  to  an  as- 
sociated rickets.  Sometimes  a  suppurative  synovitis  occurs,  usually 
bilaterally. 

The  liver  and  spleen  may  be  enlarged,  due  to  interstitial  sclerosis, 
and  the  same  changes  may  occur  in  the  lungs  {"white  pneumonia"), 
kidneys,  and  pancreas.  The  small  arteries  are  affected  with  endar- 
teritis^obliterans  and  periarteritis.     Orchitis,  with  enlargement  of 


I02  CONGENITAL   SYPHILIS 

the  body-  of  the  testis,  is  fairly  frequent.  The  central  nervous 
system  may  be  affected  with  gummata  and  meningitis. 

In  the  later  stages,  gummatous  ulceration  may  occur  in  the  skin; 
the  permanent  upper  central  incisor  teeth  appear  "peg-shaped," 
being  bevelled  to  a  chisel  edge  in  which  there  is  a  well-marked  notch 
("  Hutchinson 's  teeth  ") ;  the  eyes  are  affected  with  interstitial  keratitis, 
and  changes  occur  in  the  labyrinth  of  the  ear.  The  changes  in  the 
teeth,  eyes  and  ears  are  known  as  ''Hutchinson's  triad."  Gummata 
may  occur  in  any  organ  of  the  body,  and  the  Treponema  pallidum  has 
been  recovered  from  all  the  lesions. 

Growth  is  stunted  and  the  general  nutrition  interfered  with,  so 
that  the  body  often  appears  thin  and  marasmic,  and  the  skin  lax, 
dry  and  wrinkled. 

Symptoms. — As  a  rule  children  that  survive  do  not  show  symptoms 
of  syphilis  at  birth.  Symptoms  which  may  be  present  at  birth  are: 
Pemphigus,  snuffling,  enlargement  of  the  liver  or  spleen,  or  a  thick 
crop  of  hair,  usually  black,  known  as  the  ''syphilitic  wig."  The 
earliest  symptoms  generally  appear  from  a  few  days  to  three  months 
after  birth.  The  most  noticeable  is  marasmus.  The  child  progres- 
sively wastes,  becomes  wrinkled  and  old-looking  and  anemic,  and 
in  many  cases  dies  in  spite  of  correct  treatment.  Snuffling,  varying 
from  a  slight  stuffiness  to  absolute  blocking  of  the  nasal  passages 
with  blood-stained  pus,  is  very  characteristic,  and  interferes  with 
the  suckling  of  the  child.  Depression  of  the  bridge  of  the  nose  may 
result  from  the  necrosis  of  the  nasal  bones. 

Macular  and  papular  skin  eruptions  appear  usually  from  the  fourth 
to  the  sixth  week,  reddish  brown,  "raw-ham"  colored,  on  any  part 
of  the  body,  but  especially  on  the  face,  buttocks,  palms,  and  soles. 
They  may  spread  over  the  whole  body.  Pemphigus  appears  at  or 
shortly  after  birth,  and  generally  portends  a  fatal  issue.  The  con- 
tents of  the  bullae  which  are  most  frequent  on  the  palms,  soles,  groins 
and  axillae  are  purulent  or  sanguino-purulent.  Fissures  and  condy- 
lomata appear  about  the  mouth  and  anus,  the  former  leading  to 
the  formation  of  linear  scars  (rhagades).  At  any  stage  of  the  disease 
the  palms  and  soles  are  apt  to  have  a  deep  red,  dry  glazed  appearance, 
which  is  highly  characteristic. 

Soon  after  the  snuffles  and  skin  rashes,  laryngitis  frequently  occurs j 
causing  the  infant  to  have  a  hoarse  cry.  The  child  may  lose  the 
use  of  one  or  more  limbs — syphilitic  pseudo-paralysis — due  to  epiphy- 
sitis,  most  commonly  of  the  radius  or  humerus.     The  limb  lies 


CONGENITAL   SYPHILIS  103 

motionless,  and  the  child  cries  if  it  is  handled;  a  swelling  is  found  at 
the  affected  epiphysis.  Dactylitis  is  less  frequent;  it  appears  as  a 
spindle-shaped  swelling  of  the  proximal  phalanges,  more  commonly 
in  the  fingers  than  in  the  toes.  A  similar  process  of  periostitis  may 
form  nodes  or  bosses  on  other  bones,  particularly  round  the  anterior 
fontanelle,  where  they  are  known  as  "Parrot's  nodes.''  To  a  thin- 
ning of  the  cranial  bones,  whereby  a  sensation  of  crackling  is  com- 
municated to  the  examiner's  finger,  the  name  cranio-tahes  is  applied. 
The  testicles  may  enlarge  to  two  or  three  times  their  normal  size; 
the  swelling  is  hard  and  painless  and,  if  found  in  early  infancy,  is 
almost  pathognomonic  of  congenital  syphilis.     It  is  often  bilateral. 

Later  Symptoms. — The  skin  lesions  usually  disappear  after  the 
third  month  but,  later  on,  the  tertiary  gummatous  ulcer  may  appear. 
When  the  permanent  central  incisors  are  formed,  they  are  often 
found  to  be  peg-shaped,  narrower  at  the  apex  than  the  base,  with 
rounded  instead  of  angular  corners,  and  with  a  crescentic  notch  at 
the  cutting  edge.  Usually  between  the  ages  of  six  and  twelve, 
interstitial  keratitis  may  occur,  often  bilateral,  characterized  by 
defective  vision,  haziness  of  the  cornea,  with  spots  of  opacity  in 
its  substance,  and  small  newly  formed  blood-vessels  ramifying  over 
it.  There  is  often  an  accompanying  iritis  or  irido-choroiditis. 
General  enlargement  of  lymphatic  glands  is  not  characteristic  of  the 
congenital  as  it  is  of  the  acquired  syphilis,  but  sometimes  a  group  of 
glands  will  enlarge  and  may  be  mistaken  for  a  tuberculous  adenitis. 
Arthritis  may  occur,  is  usually  bilateral,'  and  most  frequently  affects 
the  knees.  Occasionally,  after  puberty,  the  patient  becomes  rapidly 
and  completely  deaf,  and  remains  so  in  spite  of  treatment. 

As  the  patient  passes  from  infancy  to  childhood  syphilis  of  the 
brain  may  show  itself  in  any  of  the  following  ways:  Convulsions, 
epilepsy,  juvenile  dementia  paralytica,  idiocy,  hydrocephalus,  hemi- 
plegia, mental  deficiency. 

The  fades  of  congenital  syphilis  is  very  striking;  the  square  head 
with  the  parietal  and  frontal  bosses,  the  sunken  bridge  of  the  nose, 
the  radiating  scars  around  the  angles  of  the  mouth,  the  interstitial 
keratitis,  and  the  notched  teeth. 

By  the  term  Syphilis  hereditaria  tarda,  or  late  syphilis,  is  meant 
the  condition  in  which,  without  any  sign  of  syphilis  having  been 
present  during  infancy,  symptoms  appear  in  later  childhood.  In 
these  cases,  probably,  early  symptoms  have  appeared  but  have  been 
overlooked  or  forgotten. 


I04  CONGENITAL    SYPHILIS 

Diagnosis. — The  age  of  the  patient  is  important.  Congenital 
syphiHs  appears  as  a  rule  in  the  first  three  months;  scurvy  and  tuber- 
culosis not  before  six  months;  and  rickets  not  till  the  second  year. 
A  polymorphous  skin  eruption  on  a  baby,  for  example,  a  macular 
rash  on  the  face,  a  papular  rash  on  the  palms  and  soles,  and  an 
indefinite  rash  on  the  buttocks,  is  diagnostic.  So  also  are  orchitis 
and  epiphysitis  in  a  child  under  six  months.  In  later  life,  Hutchin- 
son's teeth,  interstitial  keratitis,  and  periostitic  nodes  on  the  tibia 
are  the  most  important  diagnostic  signs.  A  positive  Wassermann 
reaction  is  a  valuable  guide.  A  mother's  history  of  repeated  mis- 
carriages or  dead-born  children  is  most  suggestive. 

Prognosis. — Children  born  with  manifestations  of  syphilis  usually 
die.  Pemphigus  and  juvenile  dementia  paralytica  are  invariably 
fatal.  Children  born  apparently  healthy,  but  showing  signs  in 
early  infancy  will,  under  appropriate  treatment  for  two  or  three 
years,  almost  certainly  escape  subsequent  manifestations  altogether. 

Treatment. — Prophylaxis  consists  in  the  thorough  treatment  of 
the  pregnant  woman  who  is  known  to  be  syphilitic. 

The  injection  of  salvarsan  is  not  suitable  for  young  children  and 
should  not  be  given  intravenously  under  the  age  of  six.  Mercury 
should  be  given  for  at  least  eighteen  months,  with  intermissions,  not 
by  injection  but  by  the  mouth.  Begin  with  }"2  gr.  of  Hydrargyrum 
cum  creta,  combined  with  2  gr.  of  sodium  bicarbonate,  three  times  a 
day,  and  at  nine  months  double  the  dose.  If  diarrhea  supervenes  add 
to  each  dose  2  gr.  of  Pulvis  cretse  compositus.  If  gastrointestinal 
symptoms  are  so  persistent  that  oral  administration  has  to  be  aban- 
doned, the  drug  may  be  given  by  inunction  of  Blue  ointment  (Massa 
Hydrargyri).  A  piece  the  size  of  an  ordinary  pea  (about  15  gr.)  is 
rubbed  daily  into  the  skin  of  the  abdomen,  back,  or  inside  of  the  arms, 
and  the  spot  covered  with  a  gauze  binder.  It  is  washed  off  next 
day.  This  is  a  dirty  and  uncertain  method;  it  cannot  be  used  where 
there  is  much  eruption,  and  may  cause  dermatitis.  It  is  a  valuable 
adjunct  to  oral  administration  where,  on  account  of  severity  of 
symptoms,  the  treatment  has  to  be  pushed  rapidly.  Another  and 
better  method  is  the  bichloride  bath.  A  wooden  wash-tub  is  filled 
with  warm  water,  3  to  4  gallons,  and  in  it  are  dissolved  20  to  30  gr.  of 
bichloride  of  mercury  and  an  equal  amount  of  ammonium  chlor- 
ide. The  child  is  placed  in  this  bath  for  fifteen  minutes  once  daily. 
Obviously,  this  method  is  only  to  be  entrusted  to  responsible  persons. 

Iodide  of  sodium  or  of  potassium  is  added  to  the  treatment  at 


CHOLERA  105 

the  age  of  about  two  months,  and  continued,  with  intermissions, 
for  eighteen  months,  the  object  being  to  remove  the  very  beginnings 
of  syphilitic  deposit. 

For  the  late  symptoms,  mercury  and  iodide  are  used  in  combina- 
tion, as  in  the  ''mixed  treatment"  of  acquired  syphilis.  The  local 
symptoms  are  treated  as  in  the  acquired  variety.  For  a  suckling 
child  with  "snuffles"  it  is  important  to  keep  the  nasal  passages 
clear  with  a  weak  alkaline  solution,  so  that  nose-breathing  may  be 
reestablished. 

The  general  nutrition,  which  is  as  a  rule  severely  affected,  needs 
the  most  careful  attention.  The  child  that  can  be  suckled  by  its 
mother  stands  an  infinitely  better  chance  of  survival  than  an  artifi- 
cially fed  infant;  and  breast  feeding  must  be  insisted  upon.  If  for 
any  reason  this  cannot  be  carried  out,  the  feeding  should  consist  of 
peptonized  milk,  suitably  diluted.  On  no  account  must  a  wet  nurse 
be  employed. 

CHOLERA 

Synonyms.^Asiatic  cholera;  epidemic  cholera;  malignant  cholera. 

Definition. — An  acute,  specific,  infectious  disease  occurring  usually 
in  epidemics,  but  may  be  endemic  in  certain  localities,  as  in  parts  of 
India;  characterized  by  violent  vomiting,  and  purging  of  a  peculiar, 
rice-water-like  fluid,  severe  muscular  cramps,  and  a  condition  of 
prostration  followed  by  collapse  and  death,  or  of  reaction  from 
collapse  with  the  subsequent  development  of  a  typhoid  state  (cholera 
typhoid) . 

Causes. — A  specific  poison,  an  endotoxin  liberated  from  the 
"comma  bacillus"  or  "spirocheta  cholerse"  of  Koch,  which  is  found 
in  great  numbers  in  the  discharges.  Cholera  is  not  highly  contagious 
in  the  usual  acceptation  of  that  word,  but  it  is  unquestionably 
infectious. 

The  evidence  seems  conclusive  that  the  cholera  stools  are  the  main, 
if  not  the  only,  channel  of  infection  and  that  the  great  cause  of  the 
propagation  of  cholera  is  the  contamination,  with  the  cholera  stools, 
of  the  water  used  for  drinking  purposes.  Contaminated  food  and 
milk  may  also  be  the  vehicle  by  which  it  spreads.  Flies  may  act  as 
carriers  of  the  contagion.  It  is  claimed  that  the  bacillus  is  inert  in 
the  intestinal  canal  unless  the  individual  is  in  the  "receptive  state" — 
that  is,  the  subject  of  intestinal  catarrh,  such  as  results  from  eating 
unripe  fruit,  and  indigestible  food,  and  beer  and  spirit  drinking.     It 


I06  •  CHOLERA 

is  also  determined  that  the  bacilli  are  destroyed  by  acids,  and  that 
if  the  stomach  be  normal,  cholera  will  not  result.  ''With  pure 
water,  pure  air,  pure  soil,  and  pure  habits,  cholera  need  not  be 
feared"   (Hart). 

Little,  if  any,  danger  exists  from  being  in  the  presence  of  the 
affected,  although  the  emanations  from  the  cholera  excreta  in  the 
atmosphere  may  generate  the  disease  if  swallowed  or  inhaled.  The 
dead  bodies  of  cholera  subjects  possess  some  infective  property, 
"the  bacteria  of  decomposition"  probably  destroying  the  cholera 
germs.  The  disease  follows  the  lines  of  human  travel;  caravans 
and  ships  are  prime  carriers  of  it.  One  attack  does  not  afford  pro- 
tection against  another. 

Pettenkofer  maintains  that  the  cholera  germs  develop  in  the  soil- 
water  of  the  earth  during  the  warm  months  and  that  they  rise  into 
the  atmosphere  as  a  miasm;  favorable  conditions  being  low-ground 
water,  porosity  and  moisture  of  soil,  and  contamination  with  organic 
matter,  especially  sewage. 

The  disease  is  usually  observed  during  the  summer  months,  and 
exempts  no  age.  Debility,  ill-health,  gastrointestinal  catarrh, 
fright,  anxiety,  fatigue,  intemperance,  and  uncleanliness  are  predis- 
posing causes.     The  incubation  period  is  from  three  to  five  days. 

Pathological  Anatomy. — The  morbid  appearances  in  the  majority 
of  cases  of  death  from  cholera  may  be  thus  summarized.  The 
temperature  generally  rises  after  death,  the  body  remaining  warm 
for  a  considerable  time.  Rigor  mortis  rapidly  ensues,  the  muscular 
contractions  being  often  so  powerful  as  to  displace  and  distort  the 
limbs.  The  skin  is  mottled  and  the  body  greatly  shrunken.  "The 
appearances  of  such  a  body  are  those  of  a  wasted  cadaver  long 
immersed  in  the  pickling  vats  of  the  dissecting-room."  The  blood 
is  dark  in  color,  and  thick.  The  arteries  are  empty  of  blood;  the 
veins,  on  the  other  hand,  are  distended.  The  organs  are,  as  a  rule, 
pale  and  shrunken.  The  stomach  and  intestinal  mucous  membranes 
are  congested  and  present  evidence  of  extravasation  and  ecchymoses, 
or  are  bleached  and  pale.  The  stomach  and  intestines  usually 
contain  a  quantity  of  whey-like  material,  having  an  alkaline  reaction, 
as  well  as  quantities  of  cast-off  epithelium  and  the  bacillus.  It  is 
thought  by  many  that  the  stripping-off  of  the  epithelium  is  a  post- 
mortem phenomenon.  The  Peyer's,  sohtary,  and  Brunner's  glands 
are  usually  enlarged  and  prominent,  and  occasionally  evidences  of 
ulceration  are  apparent  in  the  soUtary  glands,  and  sections  placed 


CHOLERA  107 

under  the  microscope  show  the  ''comma  bacillus."  The  villi  of 
the  mucous  membrane,  as  well  as  the  epithelium  of  the  small  intes- 
tines, are  stripped  off,  leaving  the  basement  membrane,  for  the  most 
part,  exposed.  The  liver  is  more  or  less  advanced  in  fatty  degenera- 
tion, presenting  a  somewhat  mottled,  yellowish  discoloration.  The 
spleen  is  usually  small.  The  kidneys  are  congested,  the  epithelium 
of  the  tubules  granular  and  detached  from  the  basement  membrane, 
blocking  up  the  tubes.  Bartholow  observed,  in  all  of  his  autopsies, 
''considerable  hyperemia  and  dilatation  of  the  vessels  of  the  medulla 
oblongata.  The  constancy  of  this  lesion  would  seem  to  indicate  a 
relationship  between  congestion  of  the  medulla  and  the  cramps." 
The  symptoms  are  in  all  probability  induced  by  the  absorption  of 
poisons  generated  by  the  microorganisms  in  the  intestinal  tract. 

Sjanptoms. — In  accordance  with  the  law  of  epidemic  infectious 
diseases,  the  onset,  course,  and  character  of  the  symptoms  vary  in 
different  cases  and  at  different  periods  in  the  same  epidemic. 

The  disease  may  either  set  in  suddenly  in  a  patient  previously  in 
good  health,  or  it  may  follow  an  attack  of  rather  severe  and  persistent 
diarrhea,  with  pain,  nausea,  vomiting,  and  depression.  Such  cases 
are  termed  cholerine,  the  stools  of  which  are  infectious. 

In  a  typical  case  there  are  three  stages:  first,  diarrhea;  second, 
collapse  (also  called  algid  stage);  third,  reaction. 

First  Stage. — This  stage  begins  with  chilliness,  excessive  thirst, 
coated  tongue,  unpleasant  taste  in  the  mouth,  slight  abdominal 
pain,  and  three  or  four  copious,  watery,  yet  fecal  stools  during  the 
day,  and  a  decided  feeling  of  weakness,  the  stools  rapidly  becoming 
whey-like,  easily  voided,  but  with  force,  and  only  slight  pain..  Occa- 
sionally an  erythematous  rash  is  present. 

Second  Stage. — The  stools  rapidly  increase  in  number,  are  voided 
with  a  rushing  force,  and  consist  of  many  quarts  of  grayish  or  whitish 
rice-water-like  fluid,  accompanied  with  forcible  vomiting,  first  of  the 
contents  'of  the  stomach,  mixed  with  more  or  less  bilious  matter, 
afterward  of  the  peculiar  rice-water-like  material;  thirst  becomes 
most  intense,  increasing  or  diminishing  with  the  variations  in  the 
number  of  the  stools  and  vomiting;  severe  muscular  cramps  soon 
follow,  most  severe  in  the  calves,  although  occurring  in  all  parts  of 
,  the  body.  The  stools,  vomiting  and  cramps  continue.  The  appear- 
ance of  the  patient  becomes  frightful;  the  eyes  are  sunken  and 
surrounded  by  blackened  rings,  the  nose  pinched  and  pointed,  the 
cheeks  hollow,  and  the  lips  blue  (facies  cholerica);  the  surface^cold 


Io8  ^  CHOLERA 

and  moistened  with  a  sticky  perspiration;  the  skin  of  the  hands  and 
fingers  has  the  sodden  appearance  of  the  '^  washerwoman  who  has 
washed  all  day"  and,  if  picked  up  in  folds,  the  fold  but  slowly  dis- 
appears. The  temperature  rapidly  falls,  the  pulse  becomes  small 
and  compressible,  barely  perceptible  at  the  wrist,  and  the  heart-beats 
are  scarcely  recognizable.  The  voice  is  weak,  husky,  and  sepulchral 
(vox  cholerica),  the  tongue  is  like  ice,  the  breath  is  cold  and  icy, 
the  urine  markedly  diminished  and  albuminous.  The  mind  is  clear, 
but  most  patients  are  apathetic  and  indifferent  to  their  danger. 
This,  the  algid  state  of  cholera,  or  cholera  asphyxia,  usually  terminates 
in  death  in  from  three  to  twelve,  twenty-four,  or  forty-eight  hours, 
but  reaction  may  be  established. 

Third  Stage. — The  temperature  of  the  body  rises,  the  pulse  gradu- 
ally becomes  fuller  and  stronger,  the  countenance  becomes  brighter, 
the  stools  less  frequent  and  more  fecal,  the  vomiting  decreases,  the 
thirst  lessens,  the  urine  increases  in  amount,  but  continues  albumin- 
ous, the  patient  entering  a  slow  convalescence,  or  typhoid  symptoms 
develop,  the  so-called  cholera  typhoid,  which  prolongs  the  recovery 
several  weeks.  Cases  are  sometimes  observed  in  which  collapse 
and  death  occur  without  any  intestinal  discharges.  These  are 
termed  cholera  sicca. 

Convalescence  is  often  prolonged  and  complicated  by  the  develop- 
ment of  severe  bed-sores,  boils,  bronchitis,  pneumonia  or  parotitis. 

The  prodromal  stage  lasts  from  a  few  hours  to  a  week;  the  stage 
of  collapse  from  a  few  hours  to  twelve  or  twenty-four  hours ;  the  stage 
of  reaction  a  few  hours,  and  the  stage  of  convalescence  several  weeks. 

Complications  and  Sequels. — Suppuration  of  the  parotid  gland, 
nephritis,  painful  tetanic  contractions  of  the  flexor  muscles  of  the 
limbs,  pneumonia,  pleurisy,  corneal  ulcers,  abscesses,  ulcers,  or 
gangrene  of  the  extremities,  profuse  sweats,  and  various  cutaneous 
eruptions. 

Diagnosis. — The  epidemic  character,  rapid  spreading,  and  great 
mortality  of  the  affection  prevents  its  being  mistaken  for  any  other 
disease,  although  isolated  cases  are  often  confounded  with  cholerine 
or  with  cholera  morbus,  the  points  of  distinction  being  very  few. 
The  ''comma  bacillus,"  however,  is  present  only  in  the  discharge 
of  true  Asiatic  cholera. 

Concerning  the  diagnosis  between  Asiatic  cholera  and  cholera 
morbus,  Osier  says:  ''It  is,  of  course,  extremely  important  to  be  able 
to  diagnose  between  the  two  affections.     This  can  only  be  done  by 


CHOLERA  109 

one  thoroughly  versed  in  bacteriological  methods,  and  conversant 
with  the  diversified  flora  of  the  intestine." 

Prognosis. — Very  unfavorable,  the  mortality  ranging  from  30 
to  80  or  even  90  per  cent.  The  prognosis  is  controlled  by  the  general 
condition  of  the  patient,  the  age,  habits,  and  the  development  of 
the  algid  state;  it  is  more  favorable  in  those  cases  which  develop 
gradually  than  in  those  in  which  it  reaches  its  acme  at  a  single  bound; 
the  very  young  or  very  old,  those  addicted  to  excesses  and  surrounded 
by  unfavorable  hygienic  conditions,  are  more  apt  to  perish  than  are 
others. 

Treatment. — The  treatment  should  always  be  instituted  as  early 
as  possible,  the  arrest  of  the  disease  in  the  diarrheal  stage  being 
comparatively  easy,  while  in  the  stage  of  collapse  it  is  an  exceptional 
occurrence. 

Strict  quarantine  must  be  immediately  established;  the  health 
authorities  should  be  notified  of  all  suspicious  cases;  '^ concealment 
is  a  crime  against  humanity." 

The  prophylactic  treatment  consists  in  isolation  of  the  patient, 
sterilization  of  the  discharges  by  chlorinated  lime  or  carbolic  acid, 
boiling  of  all  bed-linen,  napkins,  towels,  dishes,  knives,  etc.,  and,  in 
the  event  of  death,  wrapping  the  patient  in  sheets  soaked  in  bichloride 
of  mercury  solution  (i  to  1000)  until  removed  for  prompt  burial  or 
(preferably)  cremation.  Attendants  on  cholera  patients  should 
avoid  direct  communication  with  other  individuals,  and  should  be 
careful  to  thoroughly  wash  the  hands  after  contact  with  the  patient, 
and  to  protect  the  hair,  the  clothing,  and  the  shoes  by  some  covering 
that  may  be  easily  discarded.  Non-infected  individuals  in  cholera 
districts  should  be  instructed  to  drink  none  but  sterilized  water  and 
milk  and  to  partake  only  of  light,  easily  digested  food.  The  food 
supply  should  be  protected  from  contamination  by  insects.  In- 
temperance, overwork,  excitement,  and  exposure  to  cold  and  wet 
should  be  avoided,  and  gastrointestinal  disturbances  should  be 
guarded  against.  Immunization  by  means  of  protective  serums  has 
been  practised  with  some  degree  of  success,  but  has  not  yet  reached 
perfection.  Eucalyptus  oil  is  said  to  be  an  efficient  prophylactic 
agent;  it  should  be  given  twice  a  day  in  doses  of  TTtx  to  those  who  are 
exposed  to  the  infection. 

Medicinal  Treatment. — The  patient  should  be  placed  in  bed  at 
once  as  soon  as  the  symptoms  of  diarrhea  present  themselves  and 
all  food  temporarily  withheld.     Calomel   (beginning  with  two  or 


no  CHOLERA 

three  doses  of  gr.  vij  (0.45  gm.),  followed  with  small  doses,  gr.  % 
(0.048  gm.),  every  two  hours)  is  of  value  in  the  prodromal  stage, 
especially  if  there  is  any  indigestible  food  present  in  the  gastro- 
intestinal tract  (Ziemssen).  The  opiates,  mineral  acids,  and  intes- 
tinal antiseptics  are  of  great  value  in  the  early  stage.  The  following 
formula,  recommended  by  Bartholow,  is  productive  of  great  benefit: 

I^     Acid,  sulphuric  aromat f  5v  20  c.c. 

Tinct.  opii  deodorat f  5iij  12  c.c. 

M.  S. — Ten  to  20  drops  in  water  every  two  hours. 

Any  of  the  mineral  acids,  hydrochloric,  nitrohydrochloric,  or 
sulphuric,  in  doses  of  TTlx  to  xv  (0.66  to  i  c.c),  of  the  dilute  acid  are 
valuable,  especially  when  combined  with  paregoric  or  laudanum. 
Squibb's  cholera  mixture  may  also  be  employed: 

I^.     Tr.  opii, 

Spt.  camphor ae, 

Tr.  capsici aa  f 5j  30  c.c. 

Chloroformi  pur f  5iij  12  c.c. 

Alcohol q.  s.  ad  f  5v  150  c.c. 

M.  S. — Teaspoonful  every  two  hours. 

The  formula  of  the  "Sun  Cholera  Mixture"  is: 

I^.     Tr.  opii, 
Tr.  capsici, 
Tr.  rhei, 
Spt.  camphorae, 

Spt.  menthae  pip aa  f §j  30  c.c. 

M.  S. — Teaspoonful  in  water  after  each  evacuation  of  the  bowels. 

The  following  prescription  is  also  employed  in  this  stage. 

I^.     Tr.  opii, 
Tr.  capsici, 
Tr.  zingib., 
Spt.  menth.  pip., 
Spt.  chloroformi, 

Spt.  camphorae aa  f  5ss  2  c.c. 

Spt.  vin.  rect q.  s.  ad      f  §ij  60  c.c. 

M.  S. — Teaspoonful   in   hot  water  every  fifteen  minutes  until 
relief  is  afforded. 

Intestinal  antiseptics,  such  as  bismuth,  salol,  lead  acetate,  etc., 
may  be  used  with  benefit.  Peroxide  of  hydrogen  internally  has  been 
used  with  success. 


CHOLERA  III 

I^.     Hydrogen  peroxid fgij  60  c.c. 

Aquae  destillat f  §  viij  240  c.c. 

M.  S. — Cupful  every  two  hours. 

Enteroclysis  or  irrigation  of  the  intestinal  canal  with  large  amounts, 
from  I  to  3  gallons  twice  daily,  of  hot,  soaped  water,  hot  4  per  cent, 
solutions  of  hydrogen  peroxide,  or  weak  solutions  of  tannin,  or  hot 
I  per  cent,  solution  of  common  salt.  The  enteroclysis  is  accomplished 
by  means  of  a  soft-rubber  tube,  i  meter  in  length  and  of  suitable 
size,  to  be  introduced  into  the  rectum,  in  front  of  the  promontory 
of  the  sacrum,  into  and  up  through  the  sigmoid  flexure,  and  into  the 
descending  colon.  This  tube,  which  is  connected  with  a  reservoir, 
should  not  be  too  small  nor  too  large  in  order  to  facilitate  its  introduc- 
tion through  the  folds  of  the  sigmoid  portion  of  the  lower  bowel. 
In  fact,  the  greatest  difficulty  is  in  passing  the  tube  in  front  of  the 
promontory  of  the  sacrum  and  causing  it  to  enter  into  the  sigmoid 
flexure.  The  tube  should  be  of  proper  firmness  to  prevent  it  from 
bending  or  buckling  upon  itself  when  the  end  (which  in  all  cases 
should  be  rounded)  comes  into  contact  with  the  obstructing  folds  of 
the  intestine. 

In  the  second  stage  the  indications  are  to  relieve  the  pain  and 
cramps,  check  the  discharges,  and  to  support  the  patient.  The 
distressing  vomiting  will  call  for  the  use  of  lavage  of  the  stomach 
with  hydrogen  peroxide  (2  ounces  to  the  quart  of  hot  water),  iced 
champagne,  cocaine,  or  hydrocyanic  acid.  Ice  or  carbonated  waters 
may  be  given  to  allay  the  thirst.  Morphine  hypodermically  is  of 
greatest  value  in  relieving  the  muscular  cramps.  Bartholow  advises 
the  following  prescription: 

I^.     Chloral 5iij  12.0    gm. 

Morphinae  sulphat gr.  iv  0.26  gm. 

Aquse  lauro-cerasi f  §  j  30 .0    c.c. 

M.  S. — For  hypodermic  injection.     Dose  15  to  30  minims. 

The  use  of  alkalies,  such  as  sodium  bicarbonate,  has  been  found 
serviceable;  a  solution  of  0.5  to  i  per  cent,  may  be  administered 
early  in  the  disease,  and  this  amount  can  be  increased  if  the  patient 
shows  signs  of  intoxication  or  becomes  comatose. 

Locally,  hot  applications,  hot  irons,  hot  bricks,  hot-water  bottles, 
etc.,  or  an  ointment  of  chloroform  or  chloral  will  be  of  service. 
Inhalations  of  chloroform  or  ether  may  be  necessary.  Brandy, 
whiskey,  ammonia,  strychnine,  etc.,  should  be  administered  to  sustain 


112  DYSENTERY 

the  patient.  Subcutaneous,  intravenous,  and  rectal  injections  of 
hot,  normal  salt  solution  (teaspoonful  of  salt  to  quart  of  water)  are 
necessary  to  compensate  for  the  fluid  lost  by  the  discharges.  The 
astringent  rectal  irrigations  should  be  continued.  When  the  patient 
becomes  algid,  hot  baths  and  hot  applications  should  be  employed. 
In  the  stage  of  reaction,  feeding  is  renewed,  peptonized  milk, 
milk  and  lime-water,  gruels  and  similar  liquid  foods  being  allowed. 
Tonics,  such  as  iron,  arsenic,  quinine,  etc.,  should  be  given. 

DYSENTERY 

Synonym. — Bloody   flux. 

Definition. — ^An  acute  inflammation  of  the  mucous  membrane 
of  the  large  intestine;  either  catarrhal  or  croupous  in  character, 
followed  in  some  cases  with  ulceration,  characterized  by  fever, 
griping  pains,  tenesmus,  and  frequent,  small,  mucous,  and  bloody 
stools.  It  may  be  sporadic,  endemic,  or  epidemic  and  occurs  in 
four  clinical  forms:  acute  catarrhal,  amebic  or  tropical,  bacillary, 
and  chronic  dysentery. 

Causes. — The  predisposing  causes  of  all  forms  are  summer  and 
autumn  seasons,  warm  climate,  sudden  atmos- 
pheric changes,  errors  in  diet,  impure  drinking- 
water,  exposure  to  cold  and  wet,  cachectic  states, 
and  bad  hygiene. 

The  catarrhal  form  is  usually  brought  about  by  the 
ingestion  of  irritating  food.     It  is  sporadic  and  is  not 
associated  with  any  specific  microorganism.      It  fre- 
quently accompanies  the  infectious  fevers.     This 
Fig.    17.— Amceba  form,  if  prolonged,  constitutes  chronic  dysentery. 

coli.     (After    Braun.)  '        ^     ,  .  .      ,    ,  .       /  , 

{From  Greene's  Med-       1  he  ameotc  or  tropical  dysentery  is  due  to  the 

ical  Diagnosis.)  ^  ,  ..  .-,  .  ,  7-       •       .1 

presence  of  a  protozoon — the  Amceba  colt — m  the 
colon.  The  organism  is  from  15  to  20  microns  in  diameter  and 
consists  of  a  central  portion  of  granular  protoplasm  surrounded  by 
a  narrow  zone  of  clear  protoplasm.  The  organism  may  be  found 
in  the  stools,  in  the  ulcerations  of  the  colon,  and  in  the  hepatic 
abscesses  that  not  uncommonly  result.  This  variety  of  the  disease 
may  be  sporadic  or  epidemic. 

Bacillary  dysentery  (sometimes  called  croupous  or  diphtheritic 
dysentery)  is  due  to  the  Bacillus  of  Shiga,  a  microorganism  belonging 
to  the  colon-typhoid  group  of  bacilli  possessing  flagella  and  motiUty. 


DYSENTERY  II3 

It  produces  an  agglutination  reaction  with  the  blood  of  dysenteric 
patients  similar  to  the  Widal  test.  This  variety  of  the  disease  is 
common  in  temperate  and  tropical  regions,  occurring  as  pseudo- 
membranous, croupous,  ulcerative,  and  chronic  dysentery.  It  may 
be  epidemic  or  sporadic. 

Dysentery  is  not  contagious  in  the  ordinary  sense  of  the  word, 
but  is  infectious,  the  drinking-water  being  the  usual  medium  of 
infection. 

Pathological  Anatomy. — In  the  catarrhal  form  the  mucous  mem- 
brane and  submucous  coat  of  the  colon  are  swollen,  congested,  and 
edematous,  and  mucus  is  formed  in  excess.  The  follicles  are  en- 
larged and  may  become  ulcerated. 

In  amebic  or  tropical  dysentery  the  lesions  are  situated  also  in  the 
colon,  but  may  be  found  in  the  ileum.  Ulceration,  involving  the 
mucosa  and  submucosa,  is  the  characteristic  structural  change. 
This  process  is  preceded  by  the  infiltration  of  the  mucous  and  sub- 
mucous coats  with  a  grayish,  gelatinous  substance,  the  exfoliation 
of  which  produces  the  ulcer.  In  the  early  stages  these  infiltrations 
appear  as  hemispherical  elevations,  the  mucous  membrane  covering 
which  is  soon  cast  off  to  be  followed  by  sloughing  of  the  submucous 
coat  and  its  infiltrate.  The  microorganisms  are  present  in  the 
necrotic  tissue  and  by  their  migration  not  infrequently  (20  per  cent.) 
produce  abscess  of  the  liver. 

Bacillary,  croupous,  or  diphtheritic  dysentery  begins  with  intense 
congestion,  swelling,  and  edema  of  the  mucous  and  submucous 
tissue,  with  extravasations  of  blood,  and  the  whole  mucous  membrane 
is  covered  with  a  firm,  fibrinous  exudation;  the  mucous  membrane 
softens  and  sloughs,  leaving  large  ulcers  and  gangrenous  spots.  If 
recovery  occurs,  large  cicatrices  form,  which  narrow  the  caliber  of 
the  intestinal  tube.  The  mesenteric  glands  enlarge  and  soften,  and 
abscesses  form  in  them;  the  liver  becomes  the  seat  of  small  abscesses, 
from  embolic  obstruction  of  the  radicles  of  the  portal  vein;  the  heart 
muscle  is  flabby  and  more  or  less  fatty. 

Symptoms. — The  catarrhal  form  begins  gradually,  with  diarrhea, 
loss  of  appetite,  nausea,  and  very  shght  fever,  which  continues  for 
two  or  three  days,  when  the  true  dysenteric  symptoms  develop,  viz., 
pain  on  pressure  along  the  transverse  and  descending  colon,  tormina 
or  colicky  pains  about  the  umbilicus,  burning  pain  in  the  rectum, 
with  the  sensation  of  the  presence  of  a  foreign  body  and  a  constant 
desire  to  expel  it,  or  tenesmus.     The  stools  for  the  first  day  or  two 


114  DYSENTERY 

contain  more  or  less  fecal  matter,  but  they  soon  change  to  a  grayish, 
tough,  transparent  mucus,  containing  more  or  less  blood  and  pus. 
The  number  of  stools  varies  from  five  to  twenty  or  more  in  the 
twenty-four  hours.  During  the  tormina,  nausea  and  vomiting 
may  occur.  The  urine  is  scanty  and  high-colored.  The  duration  is 
about  one  week,  the  patient  rapidly  becoming  emaciated  and 
enfeebled. 

The  amebic  form  is  characterized  by  a  more  gradual  onset  and 
gradually  increasing  diarrhea.  The  stools  are  frequent,  •  bloody, 
mucoid,  and  very  fluid,  but  as  the  disease  progresses  they  become 
yellowish-gray  and  contain  mucus  and  sometimes  blood.  The  stools 
are  less  in  number  and  the  tenesmus  is  not  so  great  as  in  the  preced- 
ing variety.  Actively  moving  amcebcB  coli  are  found  in  the  evacua- 
tions, disappearing  as  the  stools  become  formed.  Fever  is  not  very 
high  and  may  be  absent.  Emaciation  is  marked.  Abscess  of  the 
liver  and  lungs  may  occur  as  complications.  The  duration  varies 
from  six  to  twelve  weeks  and  convalescence  is  protracted.  Periodic 
recrudescences  are  not  uncommon;  indeed,  the  condition  tends  to 
become  chronic. 

The  hacillary  variety  has  an  acute  onset.  The  stools  are  more 
frequent  and  contain  more  blood  and  pus,  patches  of  membrane, 
sometimes  casts  of  the  bowel,  and  portions  of  the  gangrenous  mucous 
membrane.  Nausea,  vomiting,  and  great_  prostration  and  emacia- 
tion are  present.  The  skin  is  cold,  the  pulse  is  feeble,  and  the  odor 
emanating  from  the  patient  is  fetid.  Gaseous  distention  of  the 
abdomen  is  common.  The  fever  is  high;  the  tenesmus  is  severe; 
and  the  adynamia  is  profound.  The  bacillus  of  Shiga  is  present  in 
the  discharges.  The  duration  of  the  grave  symptoms  is  three  or 
four  days,  when  collapse  and  death  occur  or  protracted  convalescence 
begins.  Hepatic  abscess,  intestinal  perforation,  arthritis,  and 
paralysis  may  occur  as  complications.  This  variety  of  the  disease 
may  become  chronic  and  ma}^  occur  in  the  course  of  heart,  lung,  or 
kidney  disease. 

Chronic  Dysentery. — A  persistence  in  the  intestinal  lesions  of  any 
of  the  acute  varieties  just  described  results  in  chronic  dysentery; 
but  bacillary  dysentery  is  the  form  that  usually  tends  to  become 
chronic.  Ulceration  is  present  in  most  cases,  but  in  others  the 
intestinal  walls  are  thickened  with  scattered  slate-colored  patches  of 
blood  extravasation  and  disintegration.  Diarrhea  and  emaciation 
are  the  principal  symptoms.     Abdominal  pain  and  tenesmus  are 


DYSENTERY  1 1 5 

slight.     Acute  exacerbations  are  frequent.     The  affection  may  last 
several  months  or  even  years. 

Diagnosis. — The  blood-stained  stools,  tenesmus,  abdominal  pain, 
and  the  history  will  aid  in  distinguishing  dysentery  from  other 
enteric  conditions.  The  variety  of  the  disease  may  be  recognized 
by  the  microorganisms  in  the  stools  and  the  symptoms. 

Acute  catarrhal  enteritis  is  not  attended  by  tenesmus  or  blood- 
stained mucoid  stools. 

Malignant  rectal  disease  is  attended  by  blood-stained  stools  and 
tenesmus  and  resembles  chronic  dysentery,  but  an  examination  will 
serve  to  clear  up  the  diagnosis. 

Intussusception  is  accompanied  by  mucoid  and  bloody  stools 
with  tenesmus,  but  the  abrupt  onset,  persistent  vomiting,  and  the 
presence  of  a  sausage-shaped  tumor  in  the  abdomen  will  distinguish 
it  from  dysentery. 

Treatment. — The  patient  should  be  confined  to  bed  in  even  the 
mildest  attack,  and  the  bed-pan  employed,  being  careful  to  thor- 
oughly disinfect  the  discharges  with  ferrous  sulphate  or  chlorinated 
lime.  The  diet  should  be  bland  and  unirritating.  Substances 
such  as  milk  and  lime-water,  beef-peptonoids,  broths,  egg-albumin, 
etc.,  may  be  given  in  acute  attacks.  A  semisolid  diet  is  permissible 
in  chronic  cases.  The  medicinal  treatment  should  be  begun  by  the 
administration  of  a  purgative,  preferably  castor  oil,  5j  (30  c.c), 
with  tincture  of  opium,  gtt.  x  to  xx  (0.65  to  1.33  gm.).  Emetine 
hydrochloride,  gr.  }i  to  ^^,  should  be  given  by  hypodermic  injection 
once  or  twice  a  day,  in  cases  of  amebic  dysentery.  Emetine  is 
considered  a  specific  for  this  form  of  dysentery ;  it  is  quickly  absorbed, 
it  takes  effect  rapidly,  and  produces  no  unfavorable  symptoms. 
When  there  is  high  fever  and  no  marked  evidence  of  adynamia, 
magnesium  sulphate,  3ij  (8  gm.),  or  Rochelle  salt,  3iv  (16.  gm.), 
may  be  given  in  water  every  hour  until  there  is  copious  purgation 
(Saline  Treatment). 

The  pain,  tenesmus,  and  peristalsis  will  require  opium  in  some 
form,  alone  or  combined  with  astringents.  A  hypodermic  injection 
of  morphine  sulphate,  gr.  34  to  3^^  (0.016  to  0.032  gm.),  given  every 
three  or  four  hours  as  required  is  very  efficient. 

I^.     Ext.  opii gr.  ss  0 .  032  gm. 

Plumbi  acetat gr.  ij  0.13    gm. 

M.  S. — Every  two  hours. 


Il6  DYSENTERY 


Or— 


I^.     Pulv.  opii gr.  ss  o .  032  gm. 

Plumbi  acetat gr-  ij  O- 13    gm. 

Pulv.  ipecac gr.  M  0.016  gm. 

M.  S. — Every  two  hours,  until  character  of  stools  changes. 

Good  results  have  followed  the  use  of  Mistura  enterica: 

I^.     Acid  sulph.  dil fgss  15  c.c. 

Tinct.  opii  deodorat f  §j  30  c.c. 

Spt.  camphorae fBj  30  c.c. 

!          Tinct.  capsici f5ss  15  c.c. 

Spt.  chloroform! fgss  15  c.c. 

Spt.  vini  gallici f  B  jss  45  c.c. 

M.  S. — One  teaspoonful  every  two  or  three  hours,  diluted. 

In  strong  young  individuals  the  very  best  prescription  possible  is: 

I^.     Magnesii  sulph 5i  4.0  gm. 

Acid,  sulph.  dil TTlx  0.6  c.c. 

\-  Tinct.  opii  deodorat TTlx  0.6  c.c. 

Aquae  chlorof ormi . . q.  s.  ad    5ij  ad  8.0  c.c. 

M,  S. — To  be  given  every  two  or  three  hours  until  feces  appear 
in  the  stools,  when  small  doses  of  opium  and  quinine  sulphate  may 
be  used. 

Hope's  original  camphor  mixture  at  times  acts  favorably: 

I^.     Acidi  nitrosi f5j  4.0  gm. 

Mist,  camphoras fSviij  240.0  gm. 

M.  et  adde 

Tr.  opii gr.  xl  1.2  gm. 

M.  S. — One-fourth  of  this  mixture  to  be  taken  every  three 
or  four  hours. 

Bismuth  subnitrate,  gr.  xxx  (2  gm.),  or  bismuth  salicylate,  gr. 
XX  (1.3  gm.),  every  two  or  three  hours  is  of  value.  Loomis  recom- 
mends ipecacuanha,  gr.  3^  (0.016  gm.),  every  half -hour  with  suffi- 
cient opium  to  secure  quietness.  The  East  Indian  physicians  employ 
it  in  amebic  and  bacillary  dysentery  in  large  doses,  20  to  60  gr. 
(1.332  to  4  gm..).  Its  administration  is  preceded  by  a  dose  of  tinc- 
ture of  opium  one-half  hour  before;  and  for  three  hours  previously 
no  food  is  allowed.  On  the  second  day  the  dose  of  ipecacuanha  is 
reduced  and  the  drug  is  combined  with  intestinal  antiseptics. 

In  children  the  following  combination  is  successful: 


DYSENTERY  1 1 7 

I^.     Pulv.  ipecacuanhse gr.  M  0.016  gm. 

Bismuth,  subnitrat gr.  v  to  x  0.32  to  0.65  gm. 

Cretae  praep gr-  iij  o  •  2  gm. 

M.  S. — Every  two  hours. 

Ringer  advocates  the  use  of  bichloride  of  mercury,  gr.  Hoo  (0.00065 
gm.),  every  hour  or  two,  claiming  that  it  soon  frees  the  evacuation 
of  blood  and  slime.  Nuclein,  gr.  j  (0.065  gm-)>  every  hour,  until 
the  character  of  the  stools  changes,  is  also  of  value. 

Serum  Treatment. — The  antidysenteric  serum  obtained  from  the 
horse  after  immunization  has  been  employed  on  animals  in  the  labora- 
tory with  success.  Shiga  has  used  it  in  many  cases  of  Japanese 
dysentery  with  a  mortality  of  about  10  per  cent,  which,  under  the 
ordinary  methods  of  treatment,  would  have  been  about  36  per  cent. 

Irrigation  of  the  rectum  with  either  tepid,  hot,  cold,  or  iced  water 
adds  greatly  to  the  patient's  comfort  and  to  the  decrease  of  the 
inflammatory  process.  A  i  to  2  per  cent,  solution  of  creolin  may 
be  used.  Osier  employs  warm  injections  of  quinine,  i  to  5000,  to 
I  to  2500,  in  amebic  dysentery  with  great  benefit  and  rapid  destruc- 
tion of  the  amebffi!.  Suppositories  of  ice,  iodoform,  or  opium  will 
afford  great  relief,  lessening  the  pain  and  tenesmus. 

Poultices,  stupes,  hot-water  bottles,  etc.,  may  be  applied  over  the 
abdomen,  but  are  seldom  very  beneficial. 

Chronic  dysentery  will  require  careful  modification  of  the  diet, 
and  rest  in  bed.  Internally,  bismuth  subnitrate,  gr.  xxx  (2  gm.), 
three  times  daily;  turpentine,  TUx  (0.6  c.c),  every  three  hours; 
silver  nitrate,  gr.  %  to  Ys,  (0.008  to  0.022  gm.),  three  times  daily; 
sulphur,  gr.  x  (0.6  gm.),  three  times  daily;  or  the  following  may  be 
administered : 

I^.     Cupri  sulphat gr-  >^  o.oii  gm. 

Ext.  opii gr.  K  0.016  gm. 

Ext.  nucis  vomicae gr.  K  o.oii  gm. 

M.     Ft.  pil.  No.  j. 

S. — To  be  taken  four  times  daily. 

Cases  which  are  continued  by  reason  of  ulcerated  patches  in  the 
colon  require  intestinal  irrigations.  Silver  nitrate,  gr.  x  to  xxx  (0.6 
to  2  gm.)  to  the  pint,  is  the  solution  of  selection.  The  patient 
should  be  placed  on  the  back  with  the  hips  elevated.  The  prelim- 
inary injection  of  a  small  quantity  of  cocaine  (4  per  cent,  solution) 
will  relieve  any  irritability  of  the  rectum.     The  irrigating  solution  is 


ii8 


TRYPANOSOMIASIS 


allowed  to  flow  into  the  bowel  through  a  long  rubber  tube  connected 
to  a  fountain  syringe,  the  bag  portion  of  which  is  elevated.  The 
injection  should  be  made  from  two  to  three  times  a  week,  employing 
from  I  to  3  pints  or  more  of  the  solution.  Alum,  sulphate  of  zinc, 
acetate  of  lead,  or  copper  sulphate  may  be  used  instead  of  silver 
nitrate  in  solution.     The  following  is  sometimes  given  by  injection: 

li.     Argent,  nitrat gr.  j  o. 065  gm. 

Tr.  opii  deodorat lUxv ,  i .  o      gm. 

Aquas  amyH fgiv  120.0      gm. 

M.  S. — Use  as  directed. 

During  convalescence,  the  internal  administration  of  cod-liver  oil, 
syrup  of  the  lactophosphate  of  lime,  and  the  following  combination 
will  be  required: 

I^.     Strychnin,  sulphat gr.  ss  0.032  gm. 

Acid,  hydrochlor.  dil f 5ij  8.0      gm. 

Tr.  gent,  comp q.  s.  ad  f giv  120.0      gm. 

M.  S. — One  teaspoonful  in  water  before  meals. 

TRYPANOSOMIASIS 


An   infectious    condition   produced   by   the  presence  of  several 

varieties  of  trypanosomes,  especially  trypano- 
soma  gambiense.  The  importance  of  the 
condition  arises  from  its  intimate  relation 
with  sleeping  sickness,  a  common  malady  in 
Africa.  The  parasites  gain  entrance  to  the 
body  by  means  of  bites  of  the  tsetse-fly, 
the  intermediate  host,  but  it  is  also  reason- 
able to  suppose  that  contaminated  drinking- 
water  is  a  cause  since  most  cases  have  been 
observed  in  regions  near  the  water's  edge. 
Among  the  symptoms  of  trypanosomiasis 
may  be  mentioned  irregular,  undulant  fever, 
especially  in  Europeans,  cutaneous  eruptions, 
muscular  weakness,  drowsiness,  rapid  pulse, 

Fig.     18.— Trypanosoma  anemia,  brcathlessncss,  inordinate  appetite, 

hominis.     (Button  and  Lav-  ,  .  ,  -r     ,     .•  /t^i 

eran.)    (From  Greene's  Med-  and    various    ocular    manifestations.     The 
tea     tagnosts.)  lymphatic  glands  are  usually  enlarged  and 

sometimes  the  size  of  the  spleen  is  increased.     The  parasite  may  be 


BUBONIC  PLAGUE  II9 

found  in  the  fluid  obtained  by  puncturing  an  enlarged  gland  more 
readily  than  in  the  blood  and  the  cerebrospinal  fluid. 

The  parasites  also  attack  horses,  rats,  monkeys,  and  fish.  African 
negroes  are  particularly  susceptible  to  the  disease,  but  the  prognosis 
is  better  in  these  individuals  than  in  Europeans  visiting  infected 
districts.  No  cases  have  been  observed  in  American  negroes.  There 
seems  to  be  no  acquired  immunity.  The  mortality  is  high  and  treat- 
ment is  ineffectual.  The  best  results  have  been  obtained  from  the 
administration  of  arsenic  (Fowler's  solution  in  doses  of  5  minims, 
gradually  increased  to  10  or  12  minims),  and  of  atoxyl  and  soamin; 
salvarsan  has  also  been  suggested.  Prophylaxis  consists  in  protec- 
tion from  the  bite  of  the  tsetse-fly. 

KALA-AZAR 

Synonyms. — Tropical  splenomegaly;  Leishman-Donovan  disease; 
Leishmaniasis;  piroplasmosis. 

Definition. — A  tropical  disease  occurring  in  China,  India,  and 
North  Africa;  caused  by  a  protozoan  parasite,  and  characterized 
by  enlarged  spleen,  fever,  hemorrhages,  anemia,  and  cachexia. 

Etiology. — The  specific  cause  is  a  protozoan  parasite  of  the  Leish- 
mania  group  (Leishman-Donovan  body) ;  it  is  supposed  to  be  caused 
by  the  bite  of  a  bed-bug. 

S5rmptoms. — The  disease  begins  with  irregular  fever,  enlarged 
spleen  and  liver;  later  on  muscular  atrophy  and  emaciation  occur; 
throughout  the  disease  a  secondary  anemia  is  present,  and  while  at 
the  first  there  may  be  a  slight  leukocytosis,  later  on  a  diminution  in 
the  number  of  the  leukocytes  is  observed.  The  parasite  may  be 
observed  in  the  leukocytes,  and  also  in  the  fluid  obtained  from  punc- 
turing the  spleen.  Irregular  hemorrhages  are  apt  to  occur  under  the 
skin  or  from  mucous  surfaces. 

Prognosis. — -The  termination  is  usually  fatal'. 

Treatment. — Quinine  is  indicated  for  the  fever;  atoxyl  and  other 
organic  preparations  of  arsenic,  and  salvarsan  have  been  suggested, 
but  little  has  been  accomplished  in  the  way  of  checking  the  disease. 

BUBONIC  PLAGUE 

Synonyms. — Black  death;  plague;  oriental  plague. 
Definition. — A  specific,  infectious  disease  of  extraordinary  viru- 
lence and  very  rapid  course,  characterized  by  inflammation  of  the 


I20  BUBONIC  PLAGUE 

lymphatic    glands    (buboes),  .  carbuncles,    pneumonia,    and    often 
hemorrhages  (Osier). 

Etiology. — The  specific  cause  is  the  bacillus  pestis,  isolated  by 
Kitasato,  which  gains  entrance  to  the  body  through  the  respiratory 
and  digestive  tracts  and  abrasions  of  the  skin  surface.  The  infec- 
tion is  conveyed  solely  by  the  flea  on  the  rat.  Hot  weather  and 
faulty  hygiene  influence  the  etiology  indirectly,  by  favoring  infesta- 
tion by  rats. 

Symptoms. — The  disease  begins,  after  an  incubation  period  of  a 
few  days  to  a  week,  with  extreme  prostration.  This  is  followed  by 
fever  (and  its  attendant  phenomena)  which  soon  assumes  a  typhoid 
type.  Hemorrhages  into  the  skin  and  mucous  membranes  are 
comm.on.  The  lymphatic  glands  enlarge,  and  on  the  second  or 
third  day  suppurating  buboes  appear  in  the  groin,  neck,  or  armpit, 
which  usually  rupture  and  discharge.  The  temperature  drops  with 
the  appearance  of  the  buboes  and  there  is  profuse  sweating. 

Prognosis. — Plague  is  the  most  fatal  of  the  epidemic  diseases,  the 
mortality  varying  from  70  to  90  per  cent.  Death  occurs  usually  on 
the  second  or  third  day. 

Treatment. — The  best  prophylactic  measure  is  to  kill  the  rats, 
or  at  any  rate  to  keep  them  outside  of  the  dwellings.  During  the 
course  of  the  disease  the  patient  should  be  made  as  comfortable  as 
possible  and  the  symptoms  combated  as  they  arise.  Purgation  and 
stimulation  are  often  of  value.  Morphine  is  necessary  for  the  relief 
of  the  pain.  Locally,  the  injection  of  bichloride  of  mercury  into  the 
buboes  has  given  good  results.  Haffkine  employs  a  preparation  of 
sterilized  bouillon  cultures  for  prophylactic  purposes  which  has  met 
with  some  degree  of  success.  Other  serums  have  also  been  used. 
According  to  Kitasato,  the  disease  may  to  a  large  extent  be  prevented 
by  the  observance  of  well-known  hygienic  rules: 

"Proper  receptacles  for  sewage  should  be  provided,  a  pure  water 
supply  afforded,  and  streams  cleansed;  all  persons  sick  of  the  disease 
isolated;  the  furniture  of  the  sick  room  washed  with  a  2  per  cent, 
carbolic  solution  in  milk  of  lime;  old  clothes  and  bedding  are  to  be 
steamed  at  2i2°F.  (ioo°C.)  for  at  least  one  hour,  or  exposed  for  a  few 
hours  to  sunlight.  If  feasible  all  infected  articles  should  be  burned. 
The  evacuations  of  the  sick  are  to  be  mixed  with  milk  of  lime,  and 
those  who  die  of  the  disease  are  to  be  buried  at  a  depth  of  3  meters 
(about  12  feet)  or,  preferably,  cremated.  After  recovery  the  patient 
is  to  be  kept  in  isolation  at  least  one  month.     All  contact  with  the 


TETANUS  121 

sick  is  to  be  avoided,  and  great  care  exercised  with  reference  to  food 
and  drink." 

TETANUS 

Synonyms. — Lockjaw;  trismus. 

Definition. — An  acute  or  subacute  infectious  disease,  character- 
ized by  muscular  rigidity,  with  paroxysms  of  tonic  convulsions  which 
recur  with  increasing  severity,  the  mind  remaining  clear. 

Varieties. 

Idiopathic  tetanus  when  no  open  wound  is  discoverable. 

Traumatic  tetanus  when  an  open  wound  is  present. 

Tetanus  neonatorum  when  it  attacks  infants. 

Lockjaw  or  trismus  when  the  jaw  alone  is  involved. 

Cephalic  tetanus  when  the  throat  and  face  are  affected. 

Cause. — The  result  of  a  specific  bacillus — the  bacillus  tetani — ■ 
which  occurs  in  the  soil,  and  usually  gains  access  to  the  system 
through  an  abrasion.  The  bacilli  remain  in  the  wound,  but  their 
toxins  (which  are  manufactured  very  rapidly)  pass  along  the  nerves 
to  the  motor  centers  where  the  disease  is  excited.  Hence  treatment 
is,  so  often,  useless.  The  incubation  period  is  from  ten  to  fifteen 
days. 

Pathological  Anatomy. — In  the  post-mortem  examinations  which 
have  been  made,  no  uniform  morbid  appearance  was  discovered  on 
microscopic  examination.  The  brain,  cord,  lungs,  and  muscles 
are  markedly  congested,  and  show  minute  hemorrhages,  such  as  are 
met  with  in  all  cases  of  death  from  convulsions,  and  which  occur 
chiefly  during  the  process  of  death. 

Symptoms. — The  onset  is  rather  sudden,  with  stiffness  of  the  jaw, 
neck,  and  tongue,  and  some  difficulty  in  swallowing,  which  increases 
in  extent,  the  stiffness  passing  down  the  spinal  muscles  to  the  legs, 
which  are  held  in  a  firm  spasm.  Gradually  tonic  spasms  develop 
which,  involving  the  jaw  muscles,  cause  "lockjaw;"  the  face  muscles, 
"risus  sardonicus;^'  neck  and  trunk  muscles,  so  that  the  patient  rests 
on  his  head  and  heels,  ^^ opisthotonos;^'  the  trunk  and  limbs  may  be 
rigid,  "  orthotonos;  "  the  body  may  be  bent  forward, ''  emprosthotonos;  " 
or  bent  to  one  side,  "  pleurosthotonos:"  these  tonic  convulsions  are 
associated  with  intense  pain  and  the  patient  suffers  the  greatest 
distress,  particularly  if  the  chest  muscles  are  involved.  Usually 
the  febrile  reaction  is  slight,  but  in  many  cases  102°  to  io4°F.  is 


122  TETANUS 

reached,  and  in  some  instances,  as  death  approaches,  io8°  to  iio°F., 
rising  still  higher  after  death.  The  pulse  may  reach  130  to  150  and 
the  respirations  30  to  45.  The  mind  remains  clear  till  the  end, 
death  being  due  to  exhaustion ;  but  sometimes  carbon  dioxide  poison- 
ing occurs.  Usually  a  wound,  not  severe,  can  be  found,  the  symp- 
toms developing  some  two  weeks  after  its  occurrence.  The 
tonic  spasms  are  developed  by  many  sources  of  irritation,  a  draught 
of  air,  shaking  of  the  bed  or  floor,  suddenly  opening  the  door  of 
the  room,  the  'presence  of  a  visitor,  or  attempts  at  speaking  or 
movement. 

Diagnosis. — The  symptoms  are  so  characteristic,  with  the  addition 
of  a  history  of  a  wound,  that  an  error  seems  hardly  probable. 

Tetany. — The  spasms  chiefly  affect  the  extremities,  the  muscles 
being  free  in  the  interval  and  trismus  a  late  or  very  rare  condition. 

Strychnine  poisoning  often  closely  resembles  tetanus,  but  there  is 
no  beginning  trismus  and  more  rapid  development  of  the  symptoms ; 
the  spasms  affect  the  entire  body,  and  in  the  intervals  between  the 
spasms  the  muscles  are  relaxed.     No  history  of  wound. 

Hydrophobia  does  not  have  trismus,  but  respiratory  spasm,  excited 
by  attempts  at  swallowing,  with  increasing  mental  symptoms. 

Prognosis. — Unfavorable.     The   great   majority   die. 

Treatment. — The  patient  should  be  placed  at  absolute  rest  in  bed 
in  a  quiet  and  darkened  room.  If  seen  early  the  wound  should  be 
thoroughly  cauterized  or  excised  and  antisepticized.  The  spasms 
will  require  the  administration  of  drugs  such  as  chloral,  potassium 
bromide,  chloralamide,  morphine  sulphate,  physostigma,  and  anti- 
pyrine.  Inhalations  of  chloroform  or  amyl  nitrite  are  often  neces- 
sary. The  administration  of  tetanus  antitoxin  by  subcutaneous 
injection  has  been  followed  by  successful  results  in  a  number  of  cases; 
but  it  must  be  done  promptly,  before  symptoms  develop.  Its  chief 
use  is  as  a  prophylactic,  and  it  should  be  used  in  conjunction  with 
other  remedies.  Quite  recently  the  intraspinal  administration  of 
antitoxin  has  been  recommended.  Nutrition  must  be  maintained 
by  rectal  alimentation.  The  hypodermic  injection  of  carboHc  acid, 
gr.  iij  (0.2  gm.)  a  day,  increasing  rapidly  until  gr.  vj  to  viij  (0.4  to 
0.5  gm.)  daily  is  reached,  has  been  highly  recommended.  Baccelli 
employs  a  2  per  cent,  solution  hypodermically  every  three  hours. 
Recently,  subarachnoid  injections  of  magnesium  sulphate  have  been 
employed;  15  minims  of  a  25  per  cent,  solution,  are  used  at  intervals 
of  24  or  48  hours. 


HYDROPHOBIA  1 23 

HYDROPHOBIA 

Synonyms. — Rabies ;  lyssa. 

Definition. — An  acute  infectious  disease,  occurring  in  the  lower 
animals,  but  communicable  to  man  by  inoculation,  characterized 
by  intense  tonic  spasm  beginning  in  the  larynx. 

Cause. — The  disease  is  due  to  a  specific  virus  which  gains  entrance 
to  the  general  circulation  of  man  by  means  of  the  bites  of  rabid 
animals.  The  poison  is  contained  in  the  medulla,  brain,  and  secre- 
tions, especially  the  saliva.  The  virus  is  supposed  to  reach  the  dog's 
salivary  glands  by  way  of  the  nerves  and  not  through  the  blood- 
vessels. Various  organisms  have  been  found,  but  their  connection 
with  the  disease  is  far  from  proved.  The  affection  in  man  is  usually 
contracted  through  the  bite  of  a  rabid  dog.  However,  not  more  than 
10  or  12  per  cent,  of  those  bitten  by  dogs  become  affected.  Bites  on 
the  hands  and  face  are  especially  liable  to  be  infected  by  the  virus, 
because  these  parts  are  exposed;  the  clothing,  when  penetrated  by 
the  teeth,  removes  much  of  the  virus.  The  period  of  incubation 
varies  from  one  week  to  two  or  more  months.  If  no  symptoms 
manifest  themselves  within  three  months,  the  patient  may  be  con- 
sidered as  unlikely  to  develop  the  disease. 

Pathological  Anatomy. — The  structural  changes  are  confined  to 
the  upper  spinal  cord,  medulla,  pons,  and  cerebral  cortex.  Negri 
has  described  in  the  central  nervous  system  irregular  bodies  found  in 
the  cells  of  these  parts ;  these  bodies  are  supposed  to  be  protozoa  and 
are  said  to  be  diagnostic.  The  blood-vessels  are  dilated  and  over- 
filled, the  perivascular  sheaths  are  infiltrated  with  leukocytes,  and 
small  hemorrhages  are  present.  The  ganglia  of  the  cerebrospinal 
and  sympathetic  systems  undergo  characteristic  changes.  The 
capsular  cells  of  the  ganglia  proliferate  leading  to  destruction  of  the 
ganglia,  with  their  replacement  by  round  cells.  Occasionally  the 
ganglion  cells  are  but  slightly  altered.  The  pharynx,  larynx,  tra- 
chea, and  bronchi  are  hyperemic. 

Symptoms. — The  first  stage  lasts  about  twenty-four  hours  and 
begins  with  pain  in  the  wound  or  its  cicatrix,  depression  of  spirits; 
irritability,  intense  mental  anxiety,  feverishness,  anorexia,  hoarse- 
ness, sleeplessness,  and  hypersensitiveness  to  noises.  This  is  followed 
by  the  second,  spasmodic,  or  furious  stage.  The  muscles  of  the 
larynx  become  extremely  irritable  and  contract  on  the  slightest 
excitation,  thus  rendering  swallowing  and  breathing  difficult.     Any 


124  HYDROPHOBIA 

attempt  to  swallow  water  or  the  accumulations  of  saliva  induces  the 
paroxysms;  hence  the  name  of  the  disease — hydrophobia — fear  of 
water.  Hyperesthesia  is  marked,  so  much  so  that  even  a  breath  of 
air  or  a  slight  noise  may  cause  the  spasms.  Delirium  and  maniacal 
excitement  are  often  present.  Fever  (io3°F.)  is  observed  also  in 
this  stage,  and  the  pulse  is  irregular.  The  duration  is  from  one  to 
three  days.  In  the  third  stage  prostration  becomes  marked  and  the 
paroxysms  subside.  The  heart  gradually  fails.  Death  follows  from 
syncope,  or  asph5rxia  from  convulsions.  This  stage  lasts  from  six  to 
eighteen  hours. 

Diagnosis. — Tetanus  is  distinguished  from  hydrophobia  by  its 
history,  short  incubation  period,  character  of  convulsions,  and  ab- 
sence of  marked  throat  symptoms.  The  extreme  mental  depression 
is  also  absent  in  tetanus. 

Hysteria  in  persons  bitten  by  animals  may  simulate  hydrophobia. 
Such  condition  is  sometimes  called  pseudohydrophobia  or  lyssophobia. 
Such  individuals  are  usually  neurotic  and  attempt  to  bark  and  bite 
and  show  many  manifestations  uncommon  in  hydrophobia.  The 
resemblance  is  often  very  close.  Subdural  injections  in  rabbits, 
of  the  central  nervous  system  of  the  animal  supposed  to  be  rabid,  will, 
in  true  hydrophobia,  be  followed  by  the  paral3rtic  form  of  the  disease 
in  fifteen  to  twenty  days. 

Prognosis. — After  the  disease  is  established  the  prognosis  is 
extremely  unfavorable.  Nearly  all  cases  die,  very  exceptionally 
spontaneous  recovery  occurs. 

Treatment. — Hydrophobia  can  be  prevented  by  a  systematic 
compulsory  muzzling  of  dogs;  in  parts  of  Germany  the  disease  has 
been  practically  eradicated.  When  a  dog  is  suspected,  it  should 
not  be  killed  but  it  should  be  tied  up  and  watched.  The  one  excep- 
tion to  this  rule  is  where  there  is  an  adequate  laboratory  at  hand; 
in  this  case  the  dog  should  be  at  once  killed  and  its  brain  examined  for 
the  presence  of  the  Negri  bodies,  which  is  diagnostic.  Prompt 
suction  followed  by  cauterization  of  the  wound  with  nitric  acid,  or 
some  strong  caustic  or  the  actual  cautery  is  advised;  nitrate  of  silver 
is  not  to  be  used  for  this  purpose.  The  wound  should  be  kept  open. 
Chloroform,  chloral,  opium,  etc.,  will  be  necessary  to  control  the 
spasms.  Nutritive  enemas  will  be  necessary  to  keep  up  the  patient's 
strength.  The  Pasteur  treatment,  consisting  of  a  series  of  inocula- 
tions of  virus,  of  increasing  strengths,  prepared  from  the  spinal 
cords    of   infected   rabbits,   should    be  tried  for  immunizing   and 


ANTHRAX  125 

curative  purposes.  The  individual  bitten  by  a  rabid  animal  should 
receive  this  treatment  immediately.  The  treatment  is  harmless 
to  a  non- infected  person. 

ANTHRAX 

Synonyms. — Malignant  pustule;  wool-sorter's  disease;  charbon; 
splenic  fever. 

Definition. — An  acute  infectious  disease  produced  by  the  bacillus 
anthracis.  It  is  essentially  a  disease  of  the  lower  animals,  especially 
cattle  and  sheep,  but  may  be  transmitted  to  man  by  contact  with 
the  bodies  of  infected  animals.  Butchers,  stable-hands,  tanners, 
wool-sorters,  etc.,  are  consequently  most  often  attacked. 

Pathological  Anatomy. — After  death,  the  body  appears  cyanotic; 
carbuncles  or  gangrenous  areas  may  appear  on  the  skin;  the  blood 
is  black,  viscid,  and  coagulates  slowly.  The  gastrointestinal  mem- 
brane is  edematous  and  ecchymotic  with  enlarged  follicles  or  glands, 
and  gangrenous  spots  in  which  the  bacilli  may  be  found.  The  nerv- 
ous tissues  are  also  affected. 

Symptoms. — After  an  incubation  period  of  about  one  week  the 
symptoms  begin  to  appear  and  may  for  convenience  be  grouped  as 
external  and  internal.  External  includes  malignant  pustule  and  ma- 
lignant anthrax  edema. 

Malignant  pustule  begins  as  a  hemorrhagic  bleb  beneath  which  a 
gangrenous  eschar  with  a  dusky  red  infiltrated  areola  forms.  It  is 
attended  by  constitutional  symptoms  such  as  fever,  increased  pulse, 
thirst,  etc.,  rapid  breathing,  enlarged  liver  and  spleen,  and  followed 
usually  by  death  within  a  few  days. 

Malignant  anthrax  edema  begins  on  the  face,  usually  about  the 
eyes,  and  extends  downward.  The  edema  is  so  great  that  gangrene 
results;  and  this  form  is  even  more  fatal  than  the  malignant  pustule. 

Internal  anthrax  is  also  of  two  kinds:  intestinal  anthrax,  and  wool- 
sorter^  s  disease. 

Intestinal  anthrax,  or  mycosis  intestinalis  may  begin  with  chill, 
nausea,  vomiting,  bloody  diarrhea,  abdominal  pain,  and  tenderness. 
It  is  due  to  eating  meat  infected  with  anthrax. 

Wool-sorter's  disease  is  due  to  inhalation  of  the  bacilli  into  the 
lungs,  and  is  characterized  by  chill,  fever,  pain,  dyspnea,  bronchitis, 
and  cough.     It  is  generally  rapidly  fatal. 

Diagnosis. — The  diagnosis  can  be  made  by  the  history,  the  charac- 
ter of  the  patient's  occupation,  the  gangrenous  patches  with  great 


126  WHOOPING   COUGH 

edema  and  infiltration,  the  marked  constitutional  symptoms,  and 
the  presence  of  the  bacillus  in  the  blood  and  the  secretions. 

Prognosis  is  always  grave;  especially  in  the  internal  varieties. 

Treatment. — The  treatment  is  largely  prophylactic.  Contami- 
nated animals  should  be  destroyed  in  their  entirety  and  disinfectants 
freely  used  in  places  where  they  have  been  housed.  In  man,  the 
lesions  should  be  subjected  to  surgical  procedures,  especially  inci- 
sions, curetment,  and  deep  cauterization.  Internally,  alcohol, 
quinine  and  other  supportive  drugs  should  be  used  to  the  point  of 
tolerance  on  account  of  the  profoundly  typhoid  state.  Powdered 
ipecac  in  doses  of  5  to  10  gr.  (0.32  to  0.64  gm.)  every  three  or  four 
hours  has  been  recommended. 

WHOOPING  COUGH 

Synonym. — Pertussis. 

Definition. — An  infectious  disease  characterized  by  a  convulsive 
paroxysmal  cough,  consisting  of  a  number  of  forcible  expirations, 
followed  by  a  series  of  deep,  loud,  sonorous  inspirations  (the  whoop), 
repeated  several  times  during  each  paroxysm,  and  associated  with 
catarrh  of  the  bronchial  tubes. 

Causes. — The  disease  is  contagious  and  is  probably  due  to  the 
Bordet-Gengou  bacillus  associated  with  the  sputum  and  mucous  dis- 
charges. It  is  a  disease  of  childhood,  fully  one-half  of  the  cases 
occur  during  the  first  two  years  of  life.  Adults  may  be  affected. 
One. attack  usually  secures  immunity. 

Pathology. — There  are  no  characteristic  structural  changes. 
The  poison  which  produces  the  disease  acts  on  the  nervous  system 
and  respiratory  mucous  membrane.  It  is  said  that  "irritation  of 
the  internal  branch  of  the  superior  laryngeal  nerve  produces  relaxa- 
tion of  the  diaphragm,  spasm  of  the  glottis,  and  a  convulsive  expira- 
tion, the  series  of  phenomena  present  in  a  paroxysm  of  asthma." 
There  is  also  hyperemia  of  the  mucous  membrane  of  the  nares, 
pharynx,  larynx,  and  bronchial  tubes,  with  diminished  secretion, 
followed  by  an  increased  secretion  of  a  transparent  mucus,  afterward 
becoming  purulent,  the  mucous  membrane  pale  and  anemic.  Fatal 
cases  are  nearly  always  due  to  extension  and  exaggeration  of  this 
congestive  condition;  and  the  pathological  conditions  found  are 
those  of  the  complications,  viz.,  bronchitis,  bronchopneumonia,  and 
collapse  of  the  lung. 


WHOOPING   COUGH  1 27 

Symptoms. — These  may  be  considered  in  three  stages:  catarrhal, 
spasmodic,  and  terminal. 

Catarrhal  stage  originates  in  an  ordinary  naso-laryngo-bronchial 
catarrh,  with  a  loose  cough.  There  is  frequently  a  leukocytosis 
(chiefly  of  lymphocytes).     Duration,  one  or  two  weeks. 

Spasmodic  Stage. — The  cough  becomes  paroxysmal,  consisting  of 
a  succession  of  short,  rapid,  expiratory  efforts,  the  face  becoming 
red,  the  eyes  swollen  and  protruding,  the  body  bending  forward, 
and  when  these  expiratory  efforts  have  exhausted  the  breath,  they 
are  followed  by  a  deep,  loud,  crowing  inspiration — the  whoop: 
each  paroxysm  being  composed  of  several  such  spells,  the  last  one 
followed  by  the  expectoration  of  a  small  amount  of  tough,  viscid 
mucus.  The  attacks  of  cough  may  be  so  severe  as  to  cause  vomiting, 
and  if  the  vomiting  occur  shortly  after  food  has  been  taken,  the 
nutrition  of  the  patient  will  suffer.  Profuse  epistaxis  is  not  infre- 
quent.    Duration,  about  four  weeks. 

Terminal  Stage. — The  paroxysms  recur  at  longer  intervals,  are  of 
shorter  duration  and  less  intensity,  the  catarrhal  symptoms  being 
more  marked,  the  expectoration  freer.  Duration,  one  or  two  weeks, 
often  followed  by  the  ''cough  of  habit." 

Complications. — The  most  common  complications  are  congestion 
of  the  lungs,  capillary  bronchitis,  pneumonia,  emphysema,  and 
collapse  of  the  lung.  Convulsions,  hydrocephalus,  and  apoplexy 
are  occasional  occurrences. 

Diagnosis. — This  is  certain  only  during  the  second  or  paroxysmal 
stage,  the  "whoop"  of  which  is  especially  characteristic  and  dis- 
tinctive. 

Prognosis. — Depends  upon  the  age  and  strength  of  the  patient, 
the  severity  of  the  paroxysms,  and  the  presence  or  absence  of  com- 
plications. Ordinary  cases  are  favorable.  Moderately  severe 
attacks  during  infancy  are  followed  by  cerebral  symptoms,  while 
attacks  occurring  in  adults  are  followed  by  chest  symptoms. 

Treatment. — There  is  no  specific  treatment.  The  disease  is  self- 
limited.  The  symptoms  may  be  modified  by  treatment  and  com- 
plications avoided.  Isolation  of  the  patient  and  disinfection  of  all 
his  personal  articles  should  never  be  neglected.  A  well-ventilated 
room,  with  plenty  of  sunHght,  should  be  selected;  but  the  patient 
need  not  be  confined  to  bed.  On  nice  days  he  should  be  allov/ed  in 
the  open  air  as  much  as  possible;  but  should  be  warmly  clad  so  as 
not  to  catch  cold.     The  diet  should  be  nutritious,  but  should  be 


128  .      WHOOPING   COUGH 

regulated  to  the  individual.  Inhalations  of  creosote  or  eucalyptol 
are  very  valuable,  dropped  upon  cotton  in  a  respirator,  or  vaporized 
over  an  alcoholic  lamp;  or  cloths  dipped  in  solutions  of  these  drugs 
may  be  hung  about  the  room. 

The  medicinal  treatment  includes  a  number  of  remedies.  Quinine 
sulphate,  in  full  doses,  and  chloral  alone  or  combined  with 
the  bromides,  belladonna  and  ipecac,  have  all  been  recommended; 
so  also  has  a  spray  of  sodium  bromide,  gr.  xx  (1.3  gm.),  fiuidextract 
of  belladonna, Tllij  (0.12  c.c),  and  water,  f5 j  (30  c.c).  Ammonium 
bromide  may  also  be  used.  At  times  benefit  may  be  obtained  from 
the  administration  of  antipyrine,  gr.  3^  to  v  (o.oii  to  0.3  gm.), 
acetanilide,  gr.  j  to  iij  (0.065  to  0.2  gm.),  every  four  hours,  or  phenace- 
tin,  gr.  j  to  ij  (0.065  to  0.13  gm.),  four  times  daily.  These  are  most 
efficacious  when  administered  in  expectorant  mixtures.  Holt  advises 
the  use  of  antipyrine  in  i  grain  (0.065  g^i-)  doses  every  three  hours 
for  a  child  six  months  old.  Terpine  hydrate,  gr.  j  to  v  (0.065  to  0.3 
gm.),  is  sometimes  valuable.  Belladonna  may  be  added  to  any  of 
the  remedies  named  with  advantage  or  the  tincture  may  be  used 
alone  in  doses  of  TTtv  to  x  (0.3  to  0.6  c.c.)  three  times  daily,  gradually 
ascending,  until  flushing  of  the  surface  is  observed,  after  which  the 
dose  is  continued  that  maintains  the  flushing. 

Starr  recommends  the  following  for  a  child  of  one  year: 

I^.     Ext.  belladonnas gr.  j  0.065  gm. 

Aluminis 5  ss  2.0      gm. 

Syr.  zingiberis, 
Syr.  acacise, 

Aquse aa  fgj     aa  30.0      c.c. 

M.   S. — A  teaspoonful  four  times  in  the  twenty-four  hours. 

Quite  recently  a  vaccine  made  from  a  culture  of  the  Bordet-Gengou 
bacillus  has  been  used,  and  it  is  said  to  be  effective. 

The  wearing  of  an  abdominal  belt  is  both  comfortable  and  useful; 
it  supports  the  abdominal  wall,  and  is  said  to  prevent  vomiting. 

During  convalescence  tonics  should  be  administered.  Cod-liver 
oil,  quinine,  iron,  etc.,  are  of  great  value  in  this  period  in  preventing 
pulmonary  sequels. 

Quarantine. — A  child  who  has  been  exposed  to  whooping-cough 
should  not  be  allowed  to  go  to  school  for  three  weeks.  And  a  child 
who  has  had  the  disease  should  not  be  allowed  to  return  to  school 
until  all  spasmodic  cough  and  whooping  have  ceased  for  at  least 
two  weeks. 


RHEUMATIC   FEVER  1 29 

RHEUMATIC  FEVER 

Synon5mis. — Acute  articular  rheumatism;  inflammatory  rheuma- 
tism; acute  rheumatism. 

Definition. — An  acute  infectious  disease,  characterized  by  fever, 
inflammation  in  and  around  the  joints,  acid  sweats,  and  a  great 
tendency  to  inflammation  of  either  the  endocardium  or  pericardium. 

Causes. — The  disease  is  believed  to  be  of  infectious  origin,  but 
no  specific  organism  has  as  yet  been  isolated;  the  favorite  at  present 
is  the  micrococcus  rheumaticus  of  Poynton  and  Paine,  but  other 
bacteria  have  also  been  found.  The  tonsils  and  diseased  teeth  are 
very  often  the  portals  of  entry  for  the  infection.  Certain  predispos- 
ing factors  seem  necessary  for  the  production  of  the  disease.  Among 
these  may  be  mentioned  exposure  to  cold  and  wet,  sudden  reductions 
in  the  temperature,  lowered  vitality  from  various  causes,  winter 
and  spring  seasons,  heredity,  infectious  fevers,  especially  scarlet 
fever,  puerperium,  male  sex,  and  previous  attacks.  The  affection 
is  seldom  observed  before  seven  or  after  fifty  years  of  age. 

Pathological  Anatomy. — The  affected  joints  are  intensely  con- 
gested and  the  synovial  membrane  and  surrounding  ligamentous 
tissues  are  greatly  swollen.  The  cartilage  may  be  eroded.  The 
synovial  fluid  is  thinner  than  normal  and  of  a  reddish  color,  con- 
taining albumin,  some  gelatinous  coagula  of  fibrin,  leukocytes,  but 
no  pus  cells  or  organismsfin  simple  cases.  There  is  an  increase  in  the 
quantity  and  in  the  number  of  white  corpuscles  in  the  blood.  The 
inflammatory  edema  of  the  joint  and  adjacent  structures  gives  rise 
to  considerable  visible  swelling  and  by  its  stretching  of  the  parts  and 
pressure  on  the  nerves  induces,  in  all  probability,  the  pain.  The  joint 
condition  usually  ends  in  resolution.  The  complications  of  this 
affection  possess  no  features  different  from  the  same  conditions  when 
occurring  independently. 

Symptoms. — Usually  the  onset  is  abrupt,  generally  at  night, 
with  a  chill  or  chilliness,  pain  and  stiffness  in  the  joints,  loss  of 
appetite,  and  at  times  nausea  and  vomiting,  followed  by  fever,  the 
temperature  soon  reaching  102°  to  io4°F.,  and  in  rare  cases  108°  to 
iio°F.  In  some  cases  it  is  preceded  by  slight  malaise,  vague  pains 
in  the  joints,  and  tonsillitis.  After  the  affection  has  begun,  there 
are  profuse  acid  sweats,  great  thirst,  constipation,  and  scanty,  high- 
colored,  acid  urine  containing  an  excess  of  uric  acid  and  urates,  and 
sometimes  traces  of  albumin.  The  fever  continues  throughout  the 
9 


130 


RHEUMATIC  FEVER 


attack,  often  with  marked  remissions.  Delirium  is  absent  except  when 
hyperpyrexia  is  present.  Sleep  is  prevented  by  the  pain  and  the  pro- 
fuse perspiration.  The  strength  is  moderately  well  preserved.  The 
skin  is  covered  with  various  forms  of  miliaria  or  prickly  heat  due  to 
excessive  irritation  of  the  sweat-glands. 

The  local  phenomena  are  pain,  increased  by  motion  and  pressure, 
tenderness,  and  increased  heat,  swelling,  and  redness  of  one  or  more 
joints.  SweUing  is  most  apparent  in  those  joints  not  covered  by 
muscle  as  the  knee,  wrist,  elbow,  and  the  ankle,  and  is  proportionate 


Fig.  19. — Clinical  chart  of  acute  articular  rheumatism  showing  renewal  of  the 
febrile  movement  consequent  upon  fresh  joint  involvement.  {JFrom  Wilcox's  Fever 
Nursing.) 


to  the  acuteness  of  the  attack.     The  inflammation  may  suddenly 
cease  in  one  or  more  joints  and  abruptly  appear  in  others. 

The  disease  is  extremely  irregular  as  regards  the  number  of  joints 
affected,  although  the  local  manifestations  are  controlled  by  an  im- 
portant pathological  law,  the  law  of  parallelism.  The  affected  joints 
are  either  on  one  side  of  the  body;  or  those  on  both  sides  that  are 
analogous,  as  the  knee  and  elbow,  wrist  and  ankle,  hip  and  shoulder, 
are  attacked  together.  This  migratory  character  of  the  inflammation 
is  especially  distinctive. 


RHEUMATIC   FEVER  I3I 

In  some  cases  the  affection  is  unattended  by  articular  manifesta- 
tions. 

Complications. — The  most  common  complications  are  endocarditis, 
pericarditis,  myocarditis,  cerebral  endarteritis,  pleurisy,  peritonitis, 
bronchitis,  pneumonia,  tonsillitis,  hyperpyrexia,  erythema  nodosum, 
urticaria,  and  purpura.  As  sequels  may  be  mentioned  chorea,  acute 
nephritis,  false  ankylosis,  chronic  rheumatism,  and  exophthalmic 
goiter. 

Duration. — The  duration  of  acute  rheumatism  is  governed  entirely 
by  the  presence  or  absence  of  complications.  UncompHcated  cases 
recover  in  from  thirteen  to  twenty-one  days,  although  they  may  be 
prolonged  to  five  or  six  weeks.     Relapses  are  frequent. 

Diagnosis. — A  typical  case  cannot  be  mistaken  for  any  other 
disease,  but  cases  running  a  subacute  course  may  be  mistaken  for 
acute  rheumatoid  arthritis,  gonorrheal  rheumatism,  or  pyemia. 

Acute  rheumatoid  arthritis  attacks  one  joint  at  a  time  and  becomes 
permanent,  has  slight,  if  any  fever,  and  no  sweats  or  cardiac  lesions. 

Gonorrheal  rheumatism  is  associated  with  a  gleety  discharge,  or 
follows  the  sudden  cessation  of  an  acute  or  subacute  gonorrhea, 
attacks  either  the  ankle  or  wrist  only,  is  slowly  influenced  by  treat- 
ment, and  lacks  the  febrile  phenomena. 

Pyemia  is  usually  manifested  in  a  single  joint  at  a  time,  and  is 
followed  by  all  the  symptoms  of  hectic  fever  and  suppuration. 

Prognosis. — Recovery  is  the  rule  in  uncomplicated  cases,  the 
mortality  being  about  3  per  cent.  When  death  occurs,  it  usually 
depends  upon  hyperpyrexia,  cardiac  complication,  or  cerebral 
endarteritis.     One  attack  predisposes  to  others. 

Treatment. — In  all  cases  the  patient  should  be  placed  at  absolute 
rest  in  bed.  He  should  wear  woolen  garments,  and  blankets  (no 
sheets)  should  constitute  the  bed  clothing,  care  being  taken  to  protect 
the  inflamed  joint  from  excessive  weight  of  the  coverings.  The  diet 
should  consist  of  easily  digested  substances,  preferably  milk.  The 
free  use  of  water,  particularly  the  alkaline  mineral  waters,  should  be 
encouraged.  In  strong  and  vigorous  patients  the  administration  of 
salicylic  acid  or  the  salicylates  in  large  and  frequently  repeated  doses 
is  of  great  benefit.  Sodium  salicylate,  ammonium  salicylate,  stron- 
tium salicylate,  salicin,  aspirin,  salol,  salophen,  or  oil  of  wintergreen 
may  be  used  and  pushed  to  the  point  of  tolerance.  In  all  cases, 
special  internal  treatment  should  be  preceded  by  a  course  of  calomel 
followed  by  a  saline  laxative. 


132  RHEUMATIC   FEVER 

I^.     Acidi  salicylici 5ss  15  gm. 

Liq.  ammonii  acetat f  5iv  120  c.c. 

Spt.  aetheris  nitrosi f  §j  30  c.c. 

Syr.  simplicis f  5j  30  c.c. 

M.  S. — Tablespoonful  every  three  hours,  well  diluted. 
Or— 

I^.     Sodii  salicylat gj  30  gm. 

Tinct.  cinchona  comp f  Siij  90  c.c. 

Aq.  menth.  pip f  Siij  90  c.c. 

M.  S. — Dessertspoonful  every  three  or  four  hours  till  relief, 
when  the  interval  should  be  increased. 
Or— 

I^.     Potassii  acetat §j  30  gm. 

Acid  salicylici §ss  15  gm. 

Syr.  limonis f  §ij  60  c.c. 

Aq.  menth.  pip f  5viij  240  c.c. 

M.  S. — Tablespoonful  every  three  hours,  diluted. 

Usually  this  treatment  affords  rather  prompt  relief  but  if  after 
three  or  four  days'  trial  there  is  no  benefit  derived  from  it,  alkaline 
treatment  should  be  substituted.  This  consists  in  the  administration 
of  an  ounce  and  a  half  of  one  of  the  alkaline  carbonates,  either  alone 
or  combined  with  a  vegetable  acid,  every  twenty-four  hours  until 
the  urine  becomes  neutral  or  alkaline  when  the  quantity  should  be 
reduced  to  an  amount  just  sufficient  to  maintain  alkalinity.  The 
following  prescriptions  are  frequently  employed: 

I^.     Potassii  bicarbonatis 5ij  8  gm. 

Acidi  tartaric! gr.  xxx  2  gm. 

M.   S. — Dissolve  in   a  glass  of  water  and  drink  effervescing 
every  three  hours. 
Or— 

I^.     Potass,  bicarb 3ij  8  gm. 

Succi  limonis f  5iv  15  c.c. 

Aqu.se  chloroformi f  5ss  15  c.c. 

M.  S. — In  water,  every  three  hours. 

After  the  acute  symptoms  have  subsided,  Basham's  mixture  or 
tincture  of  the  chloride  of  iron,  TTlxx  (1.3  c.c.)  every  three  hours, 
should  be  administered.  In  pale,  feeble,  and  anemic  patients  the 
following  prescriptions  will  be  of  great  value: 


RHEUMATIC    FEVER  1 33 

I^.     Strychninse  sulphat gr-  Ko  o.ooi   gm. 

Tinct.  ferri  chlorid TTlxv  to  xxx     i  to  2  c.c. 

Liquor,  ammonii  acetat ... .  fgss  15         c.c. 

M.  S. — Every  four  hours,  in  a  glass  of  water. 
Or— 

I^.     vSodii  salicylatis 5iv  15.0  gm. 

Glycerini f  5j  30.0  c.c. 

Acidi  citrici. . .  .  .- gr.  x  0.6  gm. 

01.  gaultheriae f5ss  2.0  c.c. 

Mucil.  acaciae fSss  150  c.c. 

M.  Add  while  stirring. 

Tinct.  ferri  chlorid f  5iv  15.0  c.c. 

Liq.    ammonii    citrat.     (B. 

P.) ad  f  5iv  ad  120.0  c.c. 

M.   S. — One  to   two  teaspoonfuls   every   two,   three,   or  four 
hours,  diluted  (S.  Solis-Cohen). 

Subacute  attacks  and  lingering  cases  are  favorably  influenced  by 

I^.     Lithii  salic3datis gr.  xv  to  xx  i  to  13  gm. 

Syr.  zingiberis f  5j 

Aq.  lauro-cerasi f  5j 

M.  S. — Every  four  hours. 
Or— 

I^.      Potassii  iodidi gr.  Ixxx 

Sodii  salicylatis 5  iv 

Elix.  cinchonas f  5jss 

Infus.  gentianae f  Bjss 

Aquae  destil f  §  j 

M.  S. — Dessertspoonful  every  three  or  four  hours,  diluted. 
These  Cases  also  do  well  with  the  use  of  salol,  gr.  v  to  x  (0.3  to  0.6 
gm.),  or  salipyrin  in  solution  every  four  hours. 

I^.      Salipyrin 5iij  12  gm. 

Glycerini f  5iij  12  c.c.     . 

Syr.  aurantii f  5vj  24  c.c. 

Aquae  destil q.  s.  ad  f  §vj  ad  180  c.c. 

M.  S. — Tablespoonful,  well  diluted. 

In  all  cases  quinine  sulphate,  gr.  xv  (i  gm.)  daily,  is  of  great  value 
especially  when  there  is  hyperpyrexia,  under  which  circumstance  it 
should  be  administered  hypodermically  and  accompanied  by  a  cold 


4 

c.c. 

4 

c.c. 

5 

•3  gm, 

15 

.0  gm. 

45- 

0  c.c. 

45. 

0  c.c. 

30. 

.  0  c.c. 

134  LOBAR  PNEUMONIA 

bath  or  wet  pack.  The  pains  will  be  relieved  to  some  extent  by  the 
coal-tar  products,  but  the  best  results  will  be  obtained  from  the  use  of 
opium  in  some  form,  or  atropine  sulphate,  gr.  }4o  (0.0008  gm.)  hypo- 
dermically,  alone  or  combined  with  morphine. 

Local  Treatment. — Rest  of  the  affected  joint  is  essential.  The 
inflamed  parts  should  be  wrapped  in  cotton-wool  or  flannel  saturated 
with  lead-water  (2  parts)  and  laudanum  (i  part),  oil  of  gaultheria, 
f5i  (4  c.c),  and  compound  soap  liniment,  f  3iij  (90  c.c),  or — 

I^.     Sodii  bicarbonatis Bij  60  gm. 

Tinct.  opii f  §ss  15  c.c. 

Aquae  bul Oij  '           960  c.c. 

M.  S. — Use  locally  as  directed. 

The  application  of  blisters,  the  size  of  a  silver  dollar,  around  the 
joint  is  very  efficacious  in  relieving  the  pain  and  lessening  the  in- 
flammation. If  the  joint  condition  tends  to  persist,  equal  parts  of 
mercurial  ointment  and  the  ointment  of  belladonna  will  be  found  of 
great  value.  Baking  of  the  joint  in  a  hot-air  apparatus  is  also  bene- 
ficial. When  the  acute  symptoms  have  subsided  massage  may  be 
employed. 

LOBAR  PNEUMONIA 

Synonyms. — Croupous  pneumonia;  pneumonitis;  fibrinous  pneu- 
monia; lung  fever. 

Definition. — An  acute,  infectious  inflammation,  involving  the 
vesicular  structure  of  the  lungs  rendering  the  alveoli  impervious 
to  air;  characterized  by  a  severe  chill,  headache,  fever,  ending  by 
crisis,  thoracic  pain,  dyspnea,  cough,  rusty  sputum,  and  great 
prostration. 

Causes. — ^Lobar  pneumonia  is  an  infectious  disease  caused  by  the 
Diplococcus  pneumonice  of  Fraenkel,  "which  has  its  seat  of  election 
in,  and  produces  its  chief  effects  on,  the  lung."  The  microorganism 
is  found  in  the  sputum  and  in  the  lungs  in  the  majority  of  cases. 
"Occasionally  other  microorganisms  seem  to  occasion  typical  fibrinous 
pneumonia.  Among  these  are  the  pneumococcus  of  Friedlander, 
streptococci,  staphylococci,  the  bacillus  of  typhoid  fever,  the  bacillus 
of  influenza,  and  the  bacillus  coli  communis.  In  some  cases  in  which 
bacteria  other  than  the  diplococcus  are  supposed  to  be  the  cause 
there  is  doubtless  mixed  infection,  but  it  must  be  accepted  at  the 


LOBAR  PNEUMONIA  135 

present  time  that  a  number  of  microorganisms  are  capable  of  causing 
the  disease"  (Stengel). 

All  ages  are  liable.  Males  are  more  frequently  affected  than 
females.  One  attack  predisposes  to  another.  Debilitating  condi- 
tions render  individuals  more  susceptible.  Alcoholism  is  among  the 
most  frequent  predisposing  factors.  The  affection  is  most  frequent 
in  winter,  at  times  occurring  epidemically,  the  result  of  atmospheric 
conditions,  and  exposure  to  draughts  and  cold.  Gout,  rheumatism, 
diabetes,  and  Bright's  disease  may  also  be  causes. 

Pathological  Anatomy. — The  most  frequent  seat  of  croupous 
pneumonia  is  the  lower  right  lobe;  the  next  most  frequent  seat  is  the 
lower  left  lobe;  the  next,  the  upper  right  lobe,  although  in  children 
and  the  aged  this  lobe  is  affected  equally  as  often  as  the  right  lower 
lobe. 

The  changes  are:  I.  Hyperemia  (engorgement);  II.  Exudation 
(red  hepatization);  III.  Resolution  (gray  hepatization);  or  the  lung 
may  undergo  purulent  transformation  with  the  development  of 
abscesses  (yellow  hepatization). 

I.  Stage  of  hyperemia,  or  congestion,  consists  in  distention  of  the 
vessel  of  the  alveoli  encroaching  on  the  cavity  of  the  air- vesicle; 
the  lung  has  a  reddish-brown  color,  is  more  resistant,  and  is  heavier, 
sinking  somewhat  lower  in  water  than  a  normal  lung,  and  having 
a  slight  exudation  upon  the  vesicular  surface.  The  same  changes 
are  seen  in  the  adjacent  bronchioles. 

II.  Stage  of  exudation  consists  in  the  exudation  of  a  viscid,  fibrinous 
fluid,  mixed  with  white  and  red  corpuscles  and  blood  rapidly  coagula- 
ting, firmly  enclosing  the  corpuscles  and  completely  filling  the  alveoli. 
When  the  exudation  and  coagulation  are  completed,  the  lung  is  red, 
sinks  at  once  when  placed  in  water,  and  its  elasticity  is  destroyed. 
When  cut,  the  color,  density,  and  granular  appearance  so  closely 
resemble  the  cut  surface  of  a  section  of  the  liver  that  Laennec  termed 
the  condition  red  hepatization.  A  thin  section  shows  under  the 
microscope,  as  a  rule,  the  lancet-shaped  diplococcus  of  Fraenkel, 
as  well  as  staphylococci  and  streptococci. 

III.  Resolution,  or  gray  hepatization  iollows  in  the  majority  of  cases, 
the  coagulated  albuminous  exudation  undergoing  liquefaction  and 
absorption,  the  cellular  element  undergoing  a  fatty  degeneration, 
the  greater  part  being  absorbed,  the  remainder  expelled  during  acts 
of  expectoration,  the  alveoli   returning  to  their  normal  condition, 


136  •    LOBAR   PNEUMONIA 

as  to  capacity,  function,  and  elasticity.  The  consolidated  area 
softens  and  becomes  mottled  gray  in  appearance.  : 

If  resolution  be  retarded  and  portions  of  the  coagulated  exudation 
undergo  purulent  transformation  changing  from  a  yellowish  to  a 
greenish-yellow  color  {yellow  hepatization),  pus  cells  are  rapidly 
formed,  the  part  becoming  a  granular,  fatty  mass.  The  portions  of 
the  lung  not  undergoing  this  purulent  transformation  retain  the 
reddish  color  with  intermixed  yellowish  patches.  The  purulent 
contents  may  be  ejected  in  part,  the  remainder  undergoing  fatty 
degeneration  and  finally  absorption. 

Abscess  of  the  lung  may  result  from  the  lung  structure  becoming 
involved  in  the  purulent  disintegration.  Abscesses  maybe  soUtary 
or  in  great  numbers,  which  by  disintegration  of  intervening  structure 
coalesce,  and  form  one  or  more  large  abscesses ;  these  abscesses  either 
terminate  fatally  or  open  into  the  pleural  cavity,  causing  empyema 
and  exhaustion,  or  open  into  the  bronchi  and  are  expectorated,  or 
an  interstitial  pneumonia  is  developed  and  the  abscess  is  encapsulated 
in  a  firm  cicatricial  tissue. 

Gangrene  of  the  lungs  may  result  from  blocking  up  of  the  bronchial 
or  pulmonary  arteries  by  coagula  during  any  stage  of  the  disease. 

The  uninflamed  portions  of  the  lungs  are  hyperemic  and  their 
functional  activity  is  increased. 

Death  sometimes  results  from  a  general  edema  of  the  unaffected 
lung,  such  cases  being  often  erroneously  termed  ^'double  pneumonia." 

If  inflammation  of  the  pleura  be  associated  with  a  pneumonia, 
the  so-called  pleuropneumonia,  the  changes  in  the  pulmonary  pleura 
are  characteristic.  *'An  uneven,  thin,  downy-looking  layer  of 
plastic  exudation  covers  its  surface.  This  plastic  layer  may  conceal 
the  liver-brown  color  of  the  pneumonic  lung.  As  the  third  stage  is 
reached,  the  opposing  surfaces  of  the  pleura  may  become  agglutinated. 
The  pleuritic  changes  follow  very  closely  those  which  occur  within  the 
lung.  The  cells  in  the  pleuritic  exudation  are  mainly  pus.  The 
pleuritic  membrane  is  opaque,  congested,  and  ecchymotic.  It  may 
become  so  thick  as  to  give  a  dull  note  on  percussion,  after  resolution 
is  reached." 

Duration  of  stages:  stage  of  congestion,  from  one  to  three  days; 
stage  of  exudation,  from  three  to  seven  days ;  stage  of  resolution,  from 
one  to  three  weeks. 

In  severe  cases,  or  in  the  very  young,- the  aged,  or  the  depressed, 


LOBAR   PNEUMONIA 


137 


the  stage  of  red  hepatization  may  be  fully  developed  within  forty- 
eight  hours.  • 

Endocarditis,  either  simple  or  malignant,  is  a  common  accom- 
paniment. Pericarditis  is  frequent.  The  spleen  is  usually  enlarged 
and  soft. 

Symptoms. — The  affection  begins  with  a  severe  and  usually  pro- 
tracted chill  (in  children  often  convulsions,  and  in  adults  sometimes 


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Fig.   20. — Clinical  chart    of    acute    pneumonia   showing   pulse   and   respiration.      De- 
fervescence upon  the  seventh  day  of  the  disease.      {From  Wilcox's  Fever  Nursing.) 

vomiting),  followed  by  a  rapid  rise  of  temperature,  103°  to  io4°F.,  a 
strong,  full,  but  rapid  pulse,  soon  showing  evidence  of  embarrassed 
cardiac  action  from  obstruction  of  the  pulmonary  circulation.  There 
are  also  present  either  a  dull  or  sharp  pain  near  the  nipple,  aggravated 
by  pressure,  breathing,  or  coughing;  shortness  of  breath,  the  inspira- 


138  •  LOBAR   PNEUMONIA       ^ 

tion  short  and  superficial,  the  expiration  accompanied  by  a  moan 
or  grunt,  the  number  of  respirations  increasing  to  40,  50,  or  more  a 
minute,  causing  interrupted  speech ;  disturbance  of  the  ratio  between 
pulse  and  respiration;  and  cough,  at  first  short,  ringing,  and  harsh, 
followed  by  a  scanty,  frothy,  mucoid  expectoration.  The  sputum 
soon  becomes  transparent,  viscid,  and  tenacious,  changing  about  the 
second  day  to  the  familiar  rusty  sputum.  The  quantity  is  increased 
and  a  yellow  color  is  assumed  as  the  disease  advances.  In  rare  in- 
stances, cases  occur  in  which  the  bloody  or  blood-streaked  sputum 
continues  throughout  the  disease.  Microscopic  examination  of  the 
sputum  in  simple  cases  shows  it  to  contain  red  blood  cells,  blood 
pigment,  pus  cells,  the  characteristic  diplococci  and  various  othei 
microorganisms. 

From  the  very  onset  of  the  disease,  the  prostration  is  of  the  most 
pronounced  character.  The  countenance  is  flushed,  and  especially 
over  the  malar  bones  there  is  a  well-defined  mahogany  blush.  The 
lips  are  more  or  less  blue  and  herpes  may  be  observed  upon  them. 
Epistaxis,  headache,  sleeplessness,  and  gastric  disturbances  are  com- 
mon. The  tongue  is  coated,  the  appetite  is  impaired,  and  there  is 
constipation.  '  Delirium  is  sometimes  present,  and  when  occurring 
early  is  a  grave  sign.  The  urine  is  small  in  amount,  highly  colored, 
deficient  in  chloiides,  and  often  slightly  albuminous.  The  blood 
shows  leukocytosis. 

The  fever  usually  reaches  its  maximum  within  twenty-four  hours 
and  continues  high,  with  diurnal  remissions,  until  either  the  fifth, 
seventh,  ninth,  or  eleventh  day,  when  a  crisis  occurs,  and  within 
twenty-four  hours  all  the  symptoms  are  decidedly  lessened,  the  fever 
absent,  and  convalescence  is  established,  followed  by  rapid  recovery. 
Occasionally,  the  termination  is  by  lysis. 

Physical  Signs. — Inspection  reveals  during  the  first  stage  deficient 
movement  of  the  affected  side,  due  to  pain.  The  apex-beat  is  normal 
in  situation,  and  the  interspaces  do  not  bulge.  In  the  second  stage 
the  healthy  side  rises  normally,  the  affected  side  lagging  behind.  If 
both  lower  lobes  are  impervious  to  air,  the  diaphragm  cannot  descend 
and  the  epigastrium  does  not  project  during  inspiration,  the  breathing 
being  conducted  by  the  upper  part  of  the  chest  (superior  costal 
respiration) . 

Palpation  during  the  first  stage  shows  the  vocal  fremitus  to  be  more 
distinct  than  normal,  especially  over  the  diseased  portions.  In 
the  second  stage,  the  vocal  fremitus  is  markedly  exaggerated,  except 


LOBAR   PNEUMONIA 


139 


in  those  rare  instances  of  occlusion  of  the  bronchi  by  secretion.  The 
cardiac  impulse  is  felt  in  the  normal  position. 

Percussion. — In  the  first  stage,  the  percussion  note  is  slightly- 
impaired  at  times,  having  a  hollow  or  tympanitic  quality.  In  the 
second  stage,  there  is  dullness  over  the  affected  parts,  with  an  in- 
creased sense  of  resistance.  Over  unaffected  adjoining  areas,  the 
resonance  is  increased  (Skoda's  resonance) . 

Auscultation. — In  the  first  stage  there  is  heard  over  the  affected 
part  a  feeble  vesicular  murmur,  associated  with  the  true  vesicular 
or  crepitant  (crackling)  r^le,  heard  at  the  end  of  inspiration  only. 
In  the  second  stage  there  is  harsh,  high-pitched,  bronchial  respiration, 
at  times  resembling  a  to-and-fro  metallic  sound,  except  in  those  rare 
instances  in  which  the  bronchi  are  more  or  less  filled  with  secretion. 
Bronchophony,  or  distinctly  transmitted  voice,  is  present  and  at  times 
pectoriloquy,  or  distinct  transmission  of  articulated  sounds,  may  be 
heard.  In  the  third  stage,  the  breathing  changes  from  bronchial  to 
broncho  vesicular  and  the  crepitant  r^le  (crepitatio  redux)  returns. 
As  resolution  proceeds,  the  breath  sounds  are  associated  with  large  and 
small  moist  and  bubbling  r^les.  According  to  DaCosta,  the  physical 
signs,  symptoms,  and  morbid  phenomena  of  this  malady  correspond 
usually  in  the  following  manner: 


I.  Stage  of  _  engorgement 
and  beginning  exuda- 
tion. 
II.  Stage  of  solidification 
of  lung  tissue  (red  he- 
patization). 


III.  Stage  of  softening  (gray 
hepatization). 


Crepitant  rile;  slight  per- 
cussion dullness. 

Percussion  dullness;  bron- 
chial respiration;  bron- 
chophony. 


The  same  physical  signs 
as  in  the  second  stage, 
unless  large  abscesses  have 
formed. 


Cough;  beginning  dyspnea 
and  rapidly  developed  fever 
heat. 

Rusty  -  colored  sputum; 

dyspnea;  cough;  high  fever 
with  marked  evening  ex- 
acerbations and  morning 
remissions. 

Chills;  prostration,  etc.; 
purulent  or  brownish  spu- 
tum; generally  high  tem- 
perature. 


Clinical  Varieties. — Typhoid  pneumonia  is  a  term  applied  to  those 
cases  which  are  accompanied  by  signs  of  extreme  prostration,  delirium, 
tremor,  very  high  temperature,  and  profuse  and  prolonged  exudation; 
they  may  also  terminate  by  a  crisis. 

Bilious  pneumonia  occurs  in  cases  accompanied  by  congestion 
of  the  liver  or  bile  ducts ;  the  result  of  venous  stasis  from  pulmonary 
obstruction  or  from  an  accompanying  acute  catarrhal  jaundice. 
In  malarial  districts  pneumonia  and  malaria  are  often  associated, 
when  jaundice  more  or  less  pronounced  occurs.  Such  cases  are  termed 
malarial  or  intermittent  pneumonia. 


140  •     LOBAR   PNEUMONIA 

Alcoholic,  or  pneumonia  of  the  intemperate,  has  one  very  character- 
istic symptom,  viz.,  early  dehrium.  In  pneumonia  generally  the 
mind  is  clear,  even  when  all  the  conditions  are  unfavorable.  Pneu- 
monia of  the  intemperate  may  begin  with  symptoms  closely  resembling 
an  attack  of  delirium  tremens,  cough,  expectoration,  and  pain  being 
very  slight,  or  even  absent. 

Pneumonia  in  the  aged  or  the  insane  may  be  latent,  coming  on 
without  chill  or  pain  and  with  only  a  slight  fever;  the  cough  and 
expectoration  are  slight,  physical  signs  ill  defined  and  changeable 
and  the  constitutional  symptoms  out  of  all  proportion  to  the  amount 
of  lung  involved. 

A  pyretic  pneumonia  is  that  which  lacks  fever,  and  is  the  result 
of  exhaustion  and  the  depressing  effect  of  the  infecting  agent  on  the 
nervous  system.     It  may  occur  as  the  result  of  embolism. 

Aspiration  pneumonia  is  due  to  the  aspiration  of  fluids  of  any  kind, 
the  disease  being  really  of  mechanical  origin. 

Traumatic  pneumonia  is  the  variety  resulting  from  severe  contusions 
of  the  chest,  the  trauma  predisposing  to  the  disease  by  mechanical 
injury  of  the  lung,  the  diplococcus  finding  suitable  nidus  at  the  site 
of  injury. 

Pneumonia  in  children  is  marked  by  nervous  phenomena.  Con- 
vulsions often  usher  in  the  attack;  and  headache,  delirium,  coma,  and 
hyperpyrexia  are  prominent  symptoms. 

In  addition  to  the  above,  pneumonia  is  said  to  be:  apical,  when  the 
apex  of  the  lung  is  affected;  basal,  when  at  the  base  of  the  lung; 
double,  when  both  lungs  are  involved;  creeping  or  migratory,  when 
different  parts  of  the  lung  or  lungs  are  successively  involved;  central, 
when  the  affection  begins  at  the  center  of  a  lobe,  and  spreads  to  the 
surface,  and  often  gives  no  physical  signs;  latent,  when  it  is  present, 
but  not  discovered  or  even  suspected;  massive,  when  a  large  portion 
of  the  lung  or  a  whole  lung  is  involved;  terminal,  when  it  occurs  in  the 
final  stage  of  many  diseases  (it  is  often  bronchopneumonia) ;  the  terms 
post-operative  and  ether  pneumonia  explain  themselves. 

Terminations. — Asthenic  cases  recover  within  two  weeks.  When 
purulent  infiltration  supervenes,  the  disease  pursues  a  tedious  course 
of  several  weeks'  duration,  with  a  low  exhaustive  fever. 

If  purulent  infiltration  follow  the  stage  of  red  hepatization,  instead 
of  the  crisis,  symptoms  of  exhaustion  occur,  with  profuse  purulent 
expectoration,  high  temperature,  severe  sweats,  the  tongue  brown 
and  dry,  sordes  collecting  on  the  gums,  low  delirium,  feeble  pulse, 


LOBAR   PNEUMONIA  I4I 

rapid,  rattling  breathing,  the  recover}''  slow,  and  convalescence  tedious. 

If  death  occurs  during  the  first  or  second  stages,  it  is  usually  the 
result  of  a  collateral  edema  of  the  uninflamed  lung,  abscess,  gangrene, 
phthisis,  or  profound  toxemia,  or  cardiac  failure  and  impaired  nerve- 
force. 

If  abscesses  occur,  there  are  exhausting  sweats,  frequent  cough, 
with  a  large  amount  of  yellowish-gray,  at  times  blood-streaked, 
expectoration. 

Gangrene  of  the  lungs  is  a  rare  termination;  it  is  associated  with 
symptoms  of  collapse,  the  expectoration  of  a  blackish,  fetid  character, 
with  the  physical  signs  of  a  pulmonary  cavity. 

Fibroid  induration  or  pulmonic  cirrhosis  and  phthisis  are  occasional 
terminations. 

Complications. — Acute  pleuritis  is  a  frequent  complication  of 
croupous  pneumonia,  occurring  in  from  10  to  25  per  cent,  of  cases. 
The  more  acute  localized  pain,  the  greater  embarrassment  of  respira- 
tion, and  the  usual  physical  signs  of  effusion  are  the  evidences  of 
a  pleuropneumonia. 

Endocarditis  is  a  common  complication,  showing  irregular  but 
protracted  temperature  record,  with  chills  and  sweats  and  great 
embarrassment  of  the  respiration. 

Meningitis  and  capillary  bronchitis  are  rare  but  dangerous  compli- 
cations.    Pericarditis,  rheumatism,  and  gout  are  rare  complications. 

Diagnosis. — Edema  of  the  lungs  may  be  confounded  with  the 
first  stage  of  pneumonia,  but  the  subsequent  history,  its  presence 
on  both  sides,  and  the  waterish  expectoration  and  absence  of  chill 
and  pain  and  the  physical  signs  of  pneumonia  soon  determine  the 
diagnosis. 

Pleurisy  is  more  often  confounded  with  pneumonia  than  any 
other  disease,  the  points  of  distinction  between  which  will  be  pointed 
out  when  discussing  that  affection. 

Typhoid  fever,  when  accompanied  by  hypostatic  congestion  of  the 
lungs,  may  be  mistaken  for  pneumonia;  the  history,  mode  of  onset, 
temperature  record,  Widal  reaction,  etc.,  will  aid  in  making  the  correct 
diagnosis.  Hypostatic  congestion  occurs  late  in  typhoid,  while 
pulmonary  congestion  is  the  earliest  manifestation  in  pneumonia. 

Acute  phthisis  may  resemble  the  affection  closely,  and  is  only 
differentiated  with  certainty  by  finding  the  tubercle  bacillus  in  the 
sputum. 

In  Bright's  disease,  valvular  heart  disease,  diabetes,  and  alcoholism. 


142  .     LOBAR   PNEUMONIA 

the  condition  of  the  lungs  should  be  ascertained  at  frequent  intervals, 
as  these  affections  are  prone  to  be  complicated  with  pneumonia. 

Prognosis. — This  depends  largely  upon  the  extent  of  the  inflam- 
mation. Double  pneumonia  is  especially  grave.  The  disease  is 
uncertain;  the  mortality  ranging  from  20  to  40  per  cent.  In  young 
adults  of  temperate  habits,  the  outlook  is,  as  a  rule,  good,  while  in 
the  aged  and  intemperate  the  prognosis  is  bad.  Pneumonia  in  drunk- 
ards almost  invariably  terminates  fatally.  Typhoid  pneumonia, 
pneumonia  in  the  insane,  bilious  pneumonia  so-called,  purulent  in- 
filtration, abscesses  of  the  lung,  and  gangrene,  all  have  a  grave  out- 
look. Heart  or  kidney  disease  influence  pneumonia  unfavorably. 
Cases  in  which  the  temperature  is  subnormal  or  is  extremely  high 
are  also  very  grave  and  seldom  recover.  A  very  rapid  pulse,  severe 
nervous  symptoms,  and  the  absence  of  leukocytosis  are  unfavorable 
symptoms .  M  eningitis  in  the  co  urse  of  pneumonia  usually  terminates 
fatally. 

Treatment. — If  pneumonia  be  regarded  as  a  constitutional  malady 
with  a  local  lesion,  then  the  consoUdated  lung  no  more  calls  for 
treatment  than  does  the  intestinal  ulcer  of  typhoid  fever,  and  the 
general  condition  of  the  patient  is  to  govern  in  the  management  and 
not  the  local  changes  in  the  thorax.  A  simple  pneumonia  attacking 
persons  previously  in  good  health  requires  no  more  active  treatment 
than  any  of  the  so-called  self -limited  diseases,  provided  only  that  the 
extent  of  the  disease  be  moderate,  and  there  be  no  complication. 

The  '^open  air  treatment^'  is  the  latest  and  best  in  the  therapeutics 
of  pneumonia.  The  patient  must  be  well  wrapped  up  and  protected, 
and  then  allowed  all  the  fresh  air  that  is  available;  it  is  beneficial  in 
every  way,  modifying  most  of  the  symptoms  and  aiding  all  forms  of 
medication.  If  patients  were  allowed  more  fresh  air  at  the  beginning 
of  the  disease,  there  would  be  less  call  for  oxygen  at  the  end;  fresh  air 
bears  about  the  same  relation  to  canned  oxygen  that  good  porter- 
house steak  does  to  embalmed  beef. 

The  patient  should  be  placed  at  rest  in  bed  in  a  moderately  heated 
and  well- ventilated  room  and  protected  from  all  draughts. 

The  diet  must  be  of  the  most  nutritious  but  easily  digestible  char- 
acter, and  given  at  periods  of  every  three  hours,  watching  that  the  food 
is  assimilated.  A  distended  stomach  and  abdomen  are  dangerous. 
Strong  black  coffee  throughout  the  disease  is  valuable.  Liquid 
or  semisoHd  substances,  such  as  milk,  broth,  eggs,  etc.,  are  especially 


LOBAR  PNEUMONIA  1 43 

serviceable.  A  cotton  jacket  should  be  applied  to  the  chest,  unless 
contraindicated  by  other  local  treatment. 

The  much-discussed  question  of  venesection  is  now  a  settled  prob- 
lem in  the  affection;  if  we  bleed,  it  is  ^^not  because  of  pneumonia, 
but  in  spite  of  pneumonia,'^  Called  to  a  patient  in  the  first  stage 
or  early  in  the  second  stage,  who  has  been  vigorous  and  otherwise 
healthy,  with  a  high  temperature,  io5°F.  or  more,  with  frequent 
pulse,  120  beats  or  more,  or  a  slow,  full  pulse  showing  cardiac  oppres- 
sion, flushed  surface,  and  marked  dyspnea,  a  copious  bleeding  is  in- 
dicated, and  the  same  may  be  said  when  symptoms  of  collateral  edema 
threaten;  this  bleeding  is  for  the  symptoms  and  not  for  the  disease 
per  se. 

There  is  no  remedy  which  is  known  to  exert  a  favorable  influence 
upon  the  pneumonic  process.  Many  cases  recover  without,  and 
many  cases  in  spite  of  treatment.  When  treatment  is  instituted, 
be  guided  by  the  fact  that  you  are  not  to  treat  pneumonia,  but  a 
patient  with  a  pneumonia. 

At  the  onset,  if  venesection  is  not  indicated,  relief  of  the  pain 
may  follow  the  use  of  dry  or  wet  cups.  If  the  tongue  be  coated 
and  the  gastrointestinal  canal  deranged,  a  calomel  purge  is  indicated. 

I^.     Hydrargyri  chloridi  mitis . .  gr.  ij  0.13    gm. 

Sodii  bicarb gr.  iv  o .  26    gm. 

Pulv.  ipecac gr.  j  0.065  gm. 

M.     Ft.  chart.  No.  iv. 

S. — One  every  two  hours,  followed  in  two  hours  after  last 
powder  by  mild  saline. 

Action  on  the  skin  and  kidneys  by  refrigerant  mixtures  or  small 
doses  of  Dover's  powder  is  valuable.  The  administration  of  the 
arterial  sedatives,  aconite  and  veratrum  viride,  is  recommended 
by  Drs.  DaCosta  and  H.  C.  Wood.  In  pneumonia  of  children, 
the  use  of  small,  frequently  repeated  doses  of  tincture  of  aconite, 
in  the  early  stage,  is  most  useful.  Continuous  creosote  inhalations 
are  very  beneficial. 

Poultices  are  of  slight  value,  but  home-made  mustard  plasters, 
weakened  with  flour,  may  be  used  in  all  stages.  If  the  heart  be  weak 
from  the  onset,  either  of  the  following  are  valuable:  digitaUs,  citrated 
caffeine,  nitroglycerine,  sparteine,  or  strychnine.  Indeed,  it  seems 
a  good  practice  to  administer  strychnine  in  full  doses  from  the  onset. 


144  -.     LOBAR   PNEUMONIA 

Quinine  sulphate,  gr.  ij  to  v  (o.  13  to  0.3  gm.)  every  three  or  four  hours, 
is  always  valuable. 

Second  Stage. — During  this  period  the  indications  are  to  maintain 
the  heart's  action  and  to  lessen  the  fever.  Cardiac  failure  being  one 
of  the  most  common  causes  of  death  in  pneumonia,  it  is  highly  im- 
portant to  sustain  the  heart  from  the  very  beginning.  Strychnine 
sulphate,  gr.  3^2  "to  ^^io  (0.002  to  0.003  g^^-)?  administered  every 
three  hours,  by  the  mouth  or  hypodermically,  citrated  caffeine,  gr. 
ij  to  V  (0.13  to  0.3  gm.),  every  four  hours,  or  tincture  of  strophanthus, 
TTLv  to  X  (0.3  to  0.6  c.c),  every  three  hours,  are  valuable  cardiac 
tonics  in  pneumonia.  The  employment  af  digitalis  and  nitroglycerine 
depends  upon  the  condition  of  the  pulse.  If  the  tension  is  low,  the 
result  of  relaxation  of  the  peripheral  blood-vessels — vasomotor 
paralysis — digitalis  in  full  doses  is  indicated;  but  if  the  tension  is 
high,  with  embarrassed  right  heart,  nitroglycerine,  combined  with 
aromatic  spirit  of  ammonia,  should  be  administered  every  hour  or 
two.  Alcoholic  stimulants  judiciously  employed  are  most  efficient 
means  of  preventing  or  overcoming  the  cardiac  failure.  The  amount 
can  only  be  determined  by  a  careful  study  of  each  case,  as  a  few 
ounces  in  the  twenty -four  hours  may  answer  in  one,  while  another  * 
may  require  8  or  10  ounces.  It  is  well  to  begin  with  small  doses, 
increasing  or  decreasing  as  its  effects  are  good  or  bad.  The  indicator 
of  the  hearths  condition  is  the  pulse.  In  the  aged,  the  feeble,  or  in  those 
accustomed  to  the  use  of  alcohol,  stimulation  is  indicated  from  the 
onset.  Other  indications  would  be  a  frequent,  feeble,  irregular,  or 
intermitting  pulse;  a  dicrotic  pulse;  delirium,  muscular  tremor,  and 
subsultus;  immediately  following  crisis,  and  the  period  of  collapse. 
Hypodermoclysis  of  normal  hot  salt  solution  is  also  recommended. 
When  collapse  threatens,  camphorated  oil  hypodermically  is  of  great 
service. 

Reduction  of  temperature  is  very  necessary  in  many  cases.  If 
the  fever  is  under  io3°F.,  cool  sponging  with  alcohol  and  water,  or 
water  alone,  is  sufficient.  If  the  temperature  is  above  io4°F.,  anti- 
febrin,  gr.  v  (0.3  gm.),  may  be  used  every  three  hours  until  a  reduction 
occurs.  Strychnine  sulphate,  or  citrated  caffeine  may  be  added  to 
each  dose.  Phenacetine  or  acentanilide  is  also  valuable,  and 
considered  less  depressing,  but  it  is  to  be  remembered  that  a  tempera- 
ture under  io4°F.,  is  as  normal  to  pneumonia  as  the  dyspnea  or  the 
rusty  sputum,  and  consequently  antipyretic  drugs  should  be  used  with 
caution.     The  use  of  the   cold  pack  or  cold   baths    for   reducing 


LOBAR   PNEUMONIA  1 45 

the  temperature  in  acute  pneumonia  has  not  given  the  success 
expected. 

The  use  of  ice-bags  to  the  chest  has  been  strongly  advocated,  and 
beneficial  results  seem  to  follow. 

For  dyspnea  and  pain  the  cardiac  stimulants  should  be  continued, 
and  in  addition  morphine  sulphate  should  be  administered  hypoder- 
mically  as  the  occasion  requires.  Counter-irritation  to  the  chest  will 
also  relieve  the  pain.  The  inhalation  of  oxygen  will  lessen  the  short- 
ness of  breath,  but  too  much  should  not  be  expected  from  this  remedy, 
as  there  is  some  additional  factor  besides  the  mechanical  one  of 
consolidation  of  the  lung  producing  the  dyspnea,  for  the  consolidation 
is  just  as  marked  immediately  after  the  crisis,  while  the  dyspnea 
is  wonderfully  relieved. 

While  the  forms  of  treatment  already  given  will  in  great  measure 
lessen  the  cough,  there  are  times  when  something  additional  is 
necessary  to  relieve  this  distressing  symptom.  In  such  cases,  mor- 
phine, codeine,  heroine,  Dover's  powder,  citrate  of  potassium,  am- 
monium chloride,  and  ammonium  carbonate,  are  especially  beneficial. 

Sleeplessness  and  delirium  are  best  overcome  by  sulphonal,  trional, 
chloralamide,  chloral,  or  the  bromides.  The  combination  of  strych- 
nine and  trional  is  of  value.  Opium  is  sometimes  necessary  but -is 
contraindicated  in  the  presence  of  pulmonary  edema  or  dypsnea. 

Third  Stage. — The  treatment  is  a  continuation  of  that  of  the 
second  stage,  with  the  addition  of  the  following  valuable  combination : 

I^.     Ammonii  chloridi gr.  v  to  x  0.3  to  0.6      gm. 

Strychninas  sulphat gr.  M4  0.003  g^i- 

Aquse  chloroformi f5j  4-o       c.c. 

Syr.  prun.  virg f  5iij  12.0       c.c. 

M.  S. — Every  three  hours,  diluted. 

In  all  cases,  the  condition  of  the  heart  should  be  carefully  watched 
and  the  medication  and  dosage  should  be  guided  largely  by  its  action. 
This  is  particularly  true  in  the  asthenic  varieties  of  the  disease. 

During  convalescence,  the  diet  should  be  highly  nutritious,  and 
iron,  quinine,  strychnine,  wine,  malt  liquors,  cod-liver  oil,  etc.,  should 
be  administered.  If  consolidation  shows  any  tendency  to  linger, 
blisters  should  be  applied  locally  and  the  iodides  administered 
internally. 

The   serum  treatment   and  the   antiseptic  treatment,   so-called, 
are  as  yet  not  generally  accepted  and  are  still  under  consideration. 
10 


146  TUBERCULOSIS 

TUBERCULOSIS 

Tuberculosis  is  an  infectious  disease  caused  by  the  invasion  of  the 
tissues  by  the  tubercle  bacillus.  It  is  characterized  by  the  formation 
"of  tubercles"  which  have  a  tendency  to  unite  and  undergo  degenera- 
tive changes  (caseous,  fibroid,  or  other).  The  lungs  are  most  fre- 
quently attacked,  but  the  pleurae,  peritoneum,  meninges,  intestinal 
tract,  bones,  and  generative  and  other  organs  may  also  be  the  seat 
of  the  disease. 

Tuberculosis  is  not,  as  a  rule,  hereditary;  but  a  predisposition  to  , 
the  disease  may  be  inherited,  and  lowered  resisting  power  to  the 
attacks  of  the  bacillus  may  also  be  inherited.  The  modes  of  infec- 
tion are:  (i)  By  inhalation;  (2)  by  ingestion  of  tuberculous  material; 
(3)  by  the  tonsils  and  lymphatics;  (4)  by  inoculation  (this  generally 
is  purely  local).  For  description  of  the  tubercle  and  the  tubercle 
bacillus,  see  pages  152  and  467. 

PULMONARY  TUBERCULOSIS 

Definition. — An  infective  disease,  caused  by  the  Bacillus  tuberculosis, 
the  lesions  of  which  are  characterized  by  nodular  bodies  called  tubercles 
or  diffused  infiltrations  of  tuberculous  tissue,  which  undergo  caseation 
or  sclerosis,  and  may  finally  ulcerate,  or,  in  some  situations,  calcify 
(Osier). 

Clinical  Varieties. — 1.  Acute  miliary  tuberculosis;  II.  Pneumonic 
phthisis;  III.  Tuberculous  phthisis;  IV.  Fibroid  phthisis. 

Cause. — It  is  now  generally  accepted  that  all  varieties  of  pulmonary 
consumption  are  due  to  the  active  presence  of  the  Bacillus  tuberculosis, 
discovered  by  Koch  in  1882.  The  lung- tissue  must  be  in  a  receptive 
state,  as  the  bacilli  may  be  present  in  the  respiratory  tract  without 
the  development  of  the  disease. 

Any  condition  that  lowers  the  tone  of  the  general  system  renders 
the  tissues  susceptible  to  the  changes  produced  by  the  tubercle 
bacilli.  These  will  be  enumerated  in  speaking  of  the  clinical  varieties 
of  the  disease. 

ACUTE  MILIARY  TUBERCULOSIS 

Sjmonjrms. — Acute  phthisis;  galloping  consumption. 
Definition. — An  acute  infectious  febrile  affection,  due  to  the  rapid 
eruption  in  various  parts  of  the  body,  but  especially  in  the  lungs, 


ACUTE   MILIARY   TUBERCULOSIS  147 

of  miliary  tubercles;  characterized  by  high  fever,  rapid  pulse,  hurried 
respiration,  pains  in  the  chest,  cough,  profuse  expectoration,  and 
rapid  prostration. 

Causes. — In  the  majority  of  cases  it  is  the  result  of  an  auto- 
infection,  arising  from  either  an  active  or  latent  tuberculous  focus. 
Cases  develop  in  which  no  cause  can  be  assigned.  It  often  follows 
measles,  whooping  cough,  variola,  and  influenza.  The  disease  is 
most  frequent  between  puberty  and  middle  life. 

"That  the  gray  granulation  be  deposited  throughout  the  body 
under  the  influence  of  certain  conditions  of  irritation,  it  is  necessary 
that  a  peculiar  vulnerabihty  of  the  constitution  exist — in  other 
words,  that  it  be  of  the  scrofulous  type." 

Pathological  Anatomy. — "The  gray  granulation,  or  miliary  tuber- 
cle consists  of  a  fine  reticulation  of  fibers,  with  a  mass  of  epithelioid 
cells  and  granules,  and  often  having  a  giant  cell  for  its  center."  The 
deposit  is  generally  over  both  lungs  and  the  bronchial  tubes,  and  is 
followed  by  hyperemia,  increase  of  secretion,  having  a  viscid  and 
adhesive  character,  and  the  destruction  of  all  the  tissue  with 
which  it  comes  in  contact. 

Deposits  also  take  place  in  the  brain,  pleura,  intestines,  peri- 
toneum, and  kidneys. 

Clinical  Forms. — General  or  typhoid,  pulmonary,  and  cerebral. 

Symptoms. — The  typhoid  variety  of  the  disease  or  generalized 
miliary  tuberculosis  is  characterized  by  gradual,  progressive  weakness, 
loss  of  appetite,  dry  clean  tongue,  constipation,  flushed  cheeks, 
irregular  fever,  the  temperature  seldom  going  above  103°  or  io4°F., 
rapid,  feeble  pulse,  and  mild  delirium.  The  respirations  are  increased 
and  in  the  early  stage  cough  and  expectoration  are  slight.  Fre- 
quently, symptoms  of  a  diffused  bronchial  catarrh  of  the  smaller 
tubes  are  present.  Excessive  sweating  is  common.  As  the  disease 
progresses,  the  prostration  becomes  more  profound,  cyanosis  de- 
velops, and  delirium,  stupor,  coma,  and  finally  death  supervene. 

Being  a  general  infection  of  asthenic  type,  it  is  liable  to  be  mis- 
taken for  typhoid  fever.  The  chief  points  of  dift'erence,  are  the 
absence  of  the  typical  typhoid  or  step-like  fever  record,  roseolar 
eruption,  diarrhea,  Widal  reaction,  and  diazo ''reaction  in  miHary 
tuberculosis.  The  presence  of  tubercle  bacilli  and  tubercles  in  the 
retina  and  choroid  are  conclusive  evidences  of  general  tuberculosis. 
The  possibility  of  malaria  should  be  eliminated  in  all  cases  by  exami- 
nation of  the  blood  for  the  Plasmodium. 


148  ACUTE   MILIARY   TUBERCULOSIS 

Acute  general  tuberculosis  always  progresses  toward  a  fatal  termi- 
nation. The  affection  seldom  lasts  more  than  six  or  eight  weeks, 
but  may  be  prolonged  for  a  greater  period.  The  treatment  is, 
therefore,  necessarily  unsatisfactory,  and  must  aim  merely  at  reliev- 
ing distressing  symptoms.  Liquid  or  semisolid  food,  such  as  milk, 
eggs,  broths,  etc.,  and  stimulants  should  be  freely  administered. 
Hydrotherapy  should  be  used  to  control  the  fever  and  anodynes 
should  be  employed  to  lessen  the  cough  and  restlessness. 

The  pulmonary  variety  is  characterized  by  sudden  onset,  with 
chill  or  chilliness,  followed  by  fever,  102°  to  io4°F.,  rapid  dicrotic 
pulse,  120  to  140  per  minute,  cough,  with  scanty,  glairy  expectoration, 
increased  respiration,  30  to  60  per  minute,  pain  in  the  chest,  hot 
skin,  dry  tongue,  and  deranged  digestion.  Prostration  is  profound. 
As  the  affection  advances,  the  symptoms  increase  in  severity;  cyano- 
sis soon  becomes  manifest;  the  sputum  becomes  more  abundant  and 
often  rusty  in  color;  hemoptysis  may  occur;  emaciation  and  anemia 
are  marked,  and  later  there  supervene  headache,  vertigo,  sleepless- 
ness, delirium,  coma,  and  death.  Tubercle  bacilli  and  elastic  fibers 
may  be  found  in  the  sputum,  and  an  examination  of  the  blood  reveals 
an  increase  in  the  number  of  white  cells  (leukocytosis).  When  the 
tubercles  are  formed  in  the  meninges  or  in  the  intestinal  wall,  symp- 
toms referable  to  these  structures  are  superadded. 

The  physical  signs  are  not  constant.  The  percussion  resonance 
is  normal  until  the  deposits  become  considerable,  when  it  is  either 
slightly  impaired  or  at  times  even  tympanitic.  With  the  develop- 
ment of  cavities,  the  amphoric  percussion-note  may  be  obtained. 
On  auscultation  often  very  little  change  may  be  detected  in  the 
vesicular  murmur,  but  diffused  rales  of  bronchial  catarrh  may  be 
heard.  In  some  cases,  vesiculo-bronchial  breathing,  associated  with 
large  and  small,  moist  or  bubbling  rales  may  be  present,  soon  followed 
by  bronchial  and  bronchocavernous  breathing,  with  large  and  small 
circumscribed  moist  and  bubbling  rales. 

This  variety  terminates  in  death  in  from  four  to  twelve  weeks. 
In  rare  instances,  it  may  be  of  several  months'  duration.  It  may  be 
mistaken  for  typhoid  fever  with  marked  pulmonary  complications, 
but  a  careful  history  and  examination  of  the  blood,  sputum,  and 
urine  will  serve  to  make  the  proper  diagnosis. 

Treatment  is  of  no  avail  in  bringing  about  a  cure.  According  to 
Loomis,  morphine,  gr.  3'^o  (o-oo3  gin.)  hypodermically  every  six 
or  eight  hours,  is  of  great  benefit  in  staying  the  progress  of  the  disease, 


PNEUMONIC   PHTHISIS  149 

prolonging  life,  and  keeping  the  patient  comfortable.  McCall 
Anderson  states  that  subcutaneous  injections  of  atropine  sulphate 
check  the  exhausting  sweats,  and  that  quinine  sulphate,  digitalis, 
and  opium  reduce  the  fever.  As  an  alternative  to  the  latter  proced- 
ures, he  advises  ice-cloths  to  the  abdomen.  Hydrotherapy  is  always 
of  value  in  this  connection.  Free  stimulation  is  always  necessary 
and  the  various  symptoms  should  be  combated  as  they  arise. 

For  the  cerebral  variety  see   Tuberculous  Meningitis  (page  538). 

PNEUMONIC  PHTHISIS 

Synon5mas. — Chronic  catarrhal  pneumonia;  catarrhal  phthisis; 
caseous  pneumonia;  caseous  phthisis;  phthisis  florida. 

Definition. — A  form  of  pulmonary  consumption  characterized  by 
the  destruction  of  the  pulmonary  tissue  resulting  from  the  action 
of  the  bacillus  tuberculosis,  causing  the  caseation  or  cheesy  degen- 
eration of  inflammatory  products  in  the  lungs,  and  the  subsequent 
softening  and  destruction  of  the  caseous  matter;  characterized  by 
hectic  fever,  cough,  shortness  of  breath,  purulent  expectoration,  and 
more  or  less  rapid  prostration. 

Causes. — In  this  as  in  other  forms  of  tuberculosis,  the  tubercle 
bacillus  is  the  primary  cause.  A  condition  of  impaired  health,  such 
as  results  from  unhygienic  surroundings,  exposure,  or  overwork,  or 
such  as  accompanies  the  strumous  diathesis  or  constitutional  diseases 
is  an  important  contributory  cause.  A  catarrhal  pneumonia  in 
any  portion  of  the  lung,  but  especially  at  the  apex,  inflammation 
occurring  around  a  blood  clot,  and  the  constant  inhalation  of  irritant 
particles  are  also  factors  of  great  etiological  importance.  In  many 
instances  the  disease  follows  one  of  the  infectious  fevers. 

Pathological  Anatomy. — The  tuberculous  infiltration  is  at  first 
peripheral  and  rapidly  leads  to  active  inflammation,  which  is  mani- 
fested as  a  bronchopneumonia,  the  bronchioles  and  air-vesicles  being 
blocked  with  cheesy  material.  As  a  result,  opaque  white  foci,  5  to  12 
mm.  in  diameter,  are  disseminated  throughout  the  lung,  between 
which  are  congested  but  crepitating  areas.  The  diseased  foci  tend 
to  soften,  rapidly  resulting  in  small  abscess  cavities.  The  tuberculous 
areas  may  be  widely  separated,  or  may  be  limited  to  certain  regions, 
especially  the  apices.  The  process,  in  rare  instances,  may  be  grafted 
•jpon  a  lobar  pneumonia  in  which  resolution  has  failed  to  occur.  It 
may  be  distinguished  from  lobar  pneumonia  by  the  greater  disinte- 


150  •  PNEUMONIC   PHTHISIS 

gration  of  tissue.  When  a  pneumonia  terminates  in  resolution,  the 
inflammatory  products  are  absorbed  by  first  undergoing  a  fatty 
metamorphosis.  .  If  the  fatty  metamorphosis  be  incomplete,  the  cells 
are  atrophied  and  undergo  the  caseous  degeneration,  which  consists 
in  the  absorption  of  the  watery  parts,  the  fatty  degeneration  of  the 
cellular  elements,  and  the  granular  disintegration  of  the  fibrinous 
material,  so  that  ultimately  a  soft,  solid  mass  is  produced,  yellowish 
in  color,  having  a  cheesy  appearance. 

The  situation  of  the  pneumonia  resulting  in  the  above  changes 
is  usually  at  the  apex  or  under  the  lower  inner  scapular  region,  but 
it  may  occur  at  any  portion  of  the  lungs,  or  a  whole  lung  becomes 
infiltrated  and  undergoes  the  cheesy  degeneration  {phthisis  florida) . 
As  in  lobar  pneumonia  and  other  pneumonic  conditions,  there  is  a 
great  tendency  toward  involvement  of  the  pleura. 

Symptoms. — Pneumonic  phthisis  occurs  in  three  chnical  forms- 
acute,  subacute,  and  chronic. 

The  acute  variety,  or  phthisis  florida,  so-called,  runs  a  very  rapid 
course,  beginning  either  as  a  croupous  or  catarrhal  pneumonia  involv- 
ing an  entire  lung  or  portions  of  both  lungs,  and  is  accompanied  by 
high,  but  variable,  temperature,  103°  to  io5°F.,  remittent  in  type, 
profuse  night-sweats,  shortness  of  breath,  severe  cough,  profuse, 
purulent,  and  blood-streaked  expectoration  containing  tubercle 
bacilli,  anorexia,  and  feeble  digestion.  There  is  rapid  loss  of  flesh 
and  strength ;  the  patient  succumbing  in  a  few  weeks  or  months  from 
exhaustion.  A  decided  remission  in  the  local  and  general  symptoms 
in  this  form  may  take  place,  the  disease  afterward  pursuing  a  more 
chronic  course. 

In  the  subacute  variety  there  is  usually  a  history  of  an  acute  attack 
of  pneumonia  of  one  or  two  weeks'  duration,  which  is  followed  by 
decided  improvement,  but  not  by  complete  recovery.  After  a 
lapse  of  some  weeks  or  months  pulmonary  softening  begins, 
destroying  the  lung  structure  and  ultimately  leading  to  cavity 
formation.  These  changes  are  accompanied  by  chills,  fever, 
night-sweats,  emaciation,  cough,  and  muco-purulent  and  blood- 
streaked  expectoration  containing  tubercle  bacilli.  The  affection 
terminates  fatally  within  a  year. 

In  the  chronic  form  the  origin  is  rather  insidious,  the  patient  having 
been  susceptible  to  ''colds"  or  "catarrhs"  on  the  slightest  exposure 
for  an  indefinite  period.  Cough  appears,  which  gradually  becomes 
persistent,  with  muco-purulent  expectoration.     Each  severe  cold  is 


PNEUMONIC   PHTHISIS  151 

accompanied  by  chill,  fever,  pain  in  the  chest,  and  either  slight 
hemorrhages  or  blood-streaked  expectoration.  Finally  the  catarrhal 
symptoms  become  persistent  and  attended  by  morning  chills,  eve- 
ning fever,  profuse  night-sweats,  distressing  cough,  and  profuse 
muco-purulent  expectoration  containing  tubercle  bacilli.  Loss  of 
appetite  and  feeble  digestion  are  present,  and  weakness  and  exhaus- 
tion are  profound.  The  symptoms  continue  to  grow  progressively 
worse,  death  occurring  from  exhaustion  in  from  one  to  two  years. 
Physical  Signs. — Inspection  shows  deficient  respiratory  movement 
over  diseased  portions  of  the  lungs.  The  respiratory  rate  is  increased. 
Palpation  over  consolidated  areas  and  cavities  detects  increased 
vocal  fremitus. 

Percussion  reveals  definite  changes  in  lungs.  The  note  at  the  apex 
varies  from  slight  impairment  of  the  normal  note  to  dullness,  and 
when  cavities  are  formed  there  will  be  associated  scattered  areas 
over  which  the  tympanic  or  hollow  note  may  be  obtained.  If  the 
cavities  communicate  with  a  bronchial  tube,  the  cracked-pot  or 
cracked-metal  sound  is  elicited.  When  the  cavities  are  filled  with 
exudation  the  percussion  note  will  be  dull,  but  after  expulsion  of  the 
exudate,  the  tympanitic  or  cracked-pot  sound  may  be  again  obtained. 
Auscultation  detects  no  impairment  of  the  vesicular  murmur  in 
those  portions  of  the  lung  free  from  disease;  it  is  feeble  or  indistinct 
if  many  bronchioles  are  obstructed,  and  is  harsh  or  blowing  if  the 
bronchioles  are  narrowed.  After  the  lung  has  lost  its  elasticity,  the 
inspiratory  sound  will  be  jerking  and  the  expiratory  sound  pro- 
longed and  blowing  in  character.  Associated  with  the  impaired 
vesicular  murmur  is  a  fine,  dry,  crackling  sound  (crepitation), 
appearing  at  the  end  of  inspiration.  If  bronchitis  be  associated, 
large  and  small  moist  or  bubbling  rales  are  also  heard  during  respira- 
tion. When  cavities  form,  either  bronchial  or  bronchocavernous 
respiration  is  heard,  associated  with  more  or  less  distinct  gurgHng 
rales.  If  the  cavity  be  free  from  pus  and  have  rather  firm  walls,  the 
breathing  is  more  amphoric  in  character. 

Diagnosis. — Catarrhal  bronchitis  has  many  points  of  resemblance 
to  pneumonic  phthisis.  The  subsequent  course  of  the  latter,  with 
the  high  temperature,  prostration,  emaciation,  sputum  containing 
bacilli,  and  physical  signs  will  prevent  error. 

Acute  fibrinous  and  catarrhal  pneumonia,  often  after  a  course  of 
two  or  three  weeks,  show  the  bacilli  and  yet  are  not  recognized  as 
tuberculosis.     It  is  a  safe  rule  in  practice  to  suspect  tuberculosis 


152  TUBERCULOUS    PHTHISIS 

and  examine  daily  for  the  bacilli  in  all  cases  of  pneumonia  that  show 
the  least  tendency  to  linger,  and  particularly  where  there  are  chills 
and  a  remittent  temperature  record. 

Prognosis. — Acute  phthisis  seldom  lasts  more  than  a  few  months, 
the  subacute  and  chronic  varieties  may  be  prolonged  for  a  year  or 
two  under  good  care  and  stimulating  treatment. 

TUBERCULOUS    PHTHISIS 

Synon5rms. — Tuberculosis;  consumption;  incipient  phthisis; 
chronic  ulcerative  phthisis. 

Definition. — A  chronic  pulmonary  disease  caused  by  the  bacillus 
tuberculosis,  resulting  in  the  deposition  of  tubercle  in  the  lung 
structure,  which  in  turn  undergoes  ulceration  and  softening,  inducing 
septic  infection,  characterized  by  progressive  failure  of  health,  fever, 
cough,  dyspnea,  emaciation,  and  exhaustion. 

Causes. — The  direct  cause  is  the  tubercle  bacillus.  A  suscepti- 
bility to  its  influence  may  be  acquired  by  heredity,  syphilis,  alcohol- 
ism, chronic  nephritis,  occupations  necessitating  cramped  postures, 
inhalation  of  foul  air  and  irritating  particles,  etc.,  residence  in  dark, 
overcrowded,  and  damp  apartments,  catarrhal  inflammation  of  the 
respiratory  tracts,  and  the  infectious  fevers.  Debility  from  any 
cause,  and  early  adult  life  are  important  predisposing  factors.  The 
infection  usually  takes  place  through  the  respiratory  tract. 

Pathological  Anatomy. — Careful  examination  of  a  lung  affected 
with  this  form  of  tuberculosis  will  reveal  a  great  variety  of  lesions. 
Among  these  may  be  mentioned  nodular  tubercles,  diffuse  infiltration, 
caseated  masses,  pneumonic  areas,  and  cavities.  Various  changes 
may  also  be  noted  in  the  pleura,  bronchi,  and  bronchial  glands. 
The  primary  lesion  is  to  be  found  usually  from  an  inch  to  an  inch 
and  a  half  below  the  summit  of  the  lung  and  near  to  the  posterior 
and  external  borders  (Fowler).  From  this  region,  the  extension  is 
downward.  "A  less  common  site  corresponds  on  the  chest  wall 
with  the  first  and  second  interspaces  below  the  outer  third  of  the 
clavicle."  The  right  apex  is  involved  first  in  the  majority  of  cases. 
Basic  lesions  are  seldom  primary. 

The  anatomical  lesion,  the  tubercle,  is  of  the  same  structure  here 
as  in  other  forms  of  tuberculosis.  It  first  appears  as  a  grayish- 
white  translucent,  semisolid  granulation,  about  the  size  of  a  millet- 
seed,  usually  deposited  in  the  walls  of  the  bronchioles  or  around 


TUBERCULOUS    PHTHISIS  1 53 

the  small  blood-vessels.  From  its  presence  in  these  situations  it 
induces  a  low  form  of  inflammation  which  ultimately  results  in  its 
destruction.  The  tubercles  then  undergo  softening  or  cheesy  necro- 
sis with  the  formation  of  cavities  and  consequent  destruction  of 
lung-tissue.  The  small  tubercles  may  coalesce,  forming  larger 
nodules,  or  diffuse  tubercular  infiltration. 

The  first  effect  of  the  tubercle  bacillus  is  the  formation  of  oval 
cells  having  a  vesicular  nucleus,  due  to  proliferation  of  the  fixed 
connective  tissue,  endothelium,  and  epithelium  {epithelioid  cells). 
These  constitute  one  of  the  characteristic  features  of  the  tubercle. 
In  the  center  of  this  accumulation  may  be  found  at  a  later  period  a 
larger  multinuclear  mass  {the  giant  cell).  Round  or  lymphoid  cells 
are  also  present  in  abundance  and  may  obscure  the  other  cellular 
elements.  New  blood-vessels  are  never  present  in  the  tubercle,  but 
the  process  may  attack  vessel  walls  leading  to  their  subsequent  rup- 
ture and  hemorrhage.  The  bacilli  are  to  be  found  in  the  giant  cells, 
between  and  in  the  epithelioid  cells,  and  at  a  late  period  in  the  round 
cells.  The  cells  soon  become  arranged  concentrically,  necrosis 
beginning  in  the  center.  The  nodule  may  terminate  in  calcification, 
but  more  commonly  the  necrosis  and  liquefaction  are  unchecked  and 
cavity  formation  is  the  result. 

The  method  by  which  the  tubercle  bacillus  may  be  detected  is 
described  in  the  introduction  to  the  section  on  respiratory  diseases 
(see  page  467). 

Symptoms. — The  onset  of  the  disease  is  very  insidious  and  is 
attended  by  anorexia,  dyspepsia,  epigastric  distress  after  meals, 
pallor,  anemia,  and  weakness,  all  of  which  may  serve  to  mislead  the 
patient  and  physician.  Later  there  develops  a  slight,  dry,  hacking 
cough,  referred  to  the  throat  or  stomach  and  occurring  usually  in  the 
morning,  with  scanty,  glairy  expectoration.  As  the  deposition  of 
the  tuberculous  disease  progresses  there  occur  irritable  heart,  gradual 
loss  of  weight,  with  impaired  strength,  more  or  less  copious  hemopty- 
sis, and  sharp  pain,  most  marked  below  the  clavicles.  Slight  "colds " 
serve  to  aggravate  all  of  these  manifestations. 

The  beginning  of  softening  of  the  diseased  area  is  marked  by 
increased  cough,  with  free  expectoration  containing  tubercle  bacilli 
and  elastic  tissue  fibers,  dyspnea  increased  on  exertion,  morning 
chills,  evening  fever,  and  night-sweats  (hectic  fever),  and  diarrhea. 
The  emaciation  and  weakness  become  profound,  but  the  patient 
continues  to  be  very  hopeful. 


154  TUBERCULOUS   PHTHISIS 

With  the  formation  of  cavities,  the  cough  becomes  more  aggra- 
vated. Expectoration  is  profuse  and  purulent;  it  may  be  greenish 
in  color  and  made  up  of  heavy  coin-shaped  plugs,  which  sink  when 
placed  in  water  (nummular  sputum).  Tubercle  bacilH  and  yellow 
striae  are  present.  The  pulse  is  rapid  and  weak.  Hectic  fever  be- 
comes more  pronounced;  the  face  is  flushed;  the  eyes  are  bright; 
a  sensation  of  burning  of  the  soles  and  palms  is  present;  and  there 
are  more  copious  night-sweats.  Hemoptysis  may  occur  at  any  time 
during  the  disease,  but  it  is  only  during  the  latter  part  of  this 
period  that  the  profuse  hemorrhages  are  encountered.  The  blood 
in  such  cases  is  bright  red,  alkaline  in  reaction,  and  mixed  with 
mucus.  The  emaciation,  pallor,  and  weakness  become  extreme. 
Edema  of  the  ankles  occurs  toward  the  end  of  the  disease,  indicating 
failure  of  the  circulation.  The  mind  remains  clear  and  hopeful  to 
the  last. 

Physical  Signs. — Inspection  during  the  early  stage  shows  slight 
depressions  in  the  supraclavicular,  and  at  times  in  the  infraclavicular, 
regions.  While  the  configuration  of  the  chest  may  be  unchanged,  it 
is  more  common  to  encounter  the  long,  flat  chest,  with  oblique  ribs, 
prominent  scapulse,  and  deep  depressions  above  and  below  the  clavi- 
cles on  either  side  (phthisical  chest).  As  the  disease  advances,  the 
emaciation,  unilateral  expansion,  and  localized  retraction  may  be 
observed. 

Palpation  serves  to  detect  increased  vocal  fremitus  over  either  or 
both  apices,  and  imperfect  expansion. 

Percussion  yields  a  slightly  impaired  note  in  the  early  stage  at 
either  or  both  apices.  When  the  manifestations  of  the  disease  are 
prominent,  dullness  may  be  obtained  over  the  consolidated  areas. 
The  regions  in  which  it  is  most  readily  elicited  are  above  and  below 
the  clavicles,  in  the  supraspinous  fossae,,  and  between  the  scapulae. 
In  the  period  of  cavity-formation  dullness  may  be  detected  with 
circumscribed  areas  of  the  amphoric,  tympanitic,  or  cracked-pot 
sound.  In  order  to  obtain  the  cracked-pot  sound  over  cavities,  the 
patient  should  hold  the  mouth  open  and  the  chest  should  be  struck 
quickly  and  lightly. 

Auscultation  reveals,  in  the  early  stage,  jerky  inspiration  with 
crackling  rales  at  the  apex,  and  prolonged,  high  pitched  expiration. 
Later  the  breathing  becomes  distinctly  harsh  and  is  associated  with 
subcrepitant,  and  large,  moist,  or  bubbling  r^les.  There  is  increased 
vocal  resonance.     Coughing  will  always  serve  to  render  the  r§,les 


TUBERCULOUS   PHTHISIS  1 55 

audible.  In  the  stage  of  cavity-formation  bronchial,  bronchovesicu- 
lar,  and  cavernous  or  amphoric  breathing  are  obtained,  and  variously 
sized  bubbling  or  gurgling  r^les  are  heard.  Bronchophony  and 
pectoriloquy  may  be  elicited. 

Complications.-^The  tuberculous  process  may  simultaneously 
affect  the  brain  and  its  membranes,  nerves  of  special  sense,  larynx, 
pleura,  intestines,  peritoneum,  ischiorectal  cellular  tissue,  endocar- 
dium, or  pericardium,  the  symptoms  of  which  are  then  superadded  to 
those  referable  to  the  pulmonary  condition.  Amyloid  degeneration 
of  the  viscera  is  a  common  complication. 

Diagnosis. — The  early  diagnosis  of  phthisis  rests  largely  on  the 
history,  the  symptoms,  especially  the  gastric  disturbances,  evening 
fever,  and  accelerated  pulse,  and  the  physical  signs.  The  presence 
of  the  tubercle  bacillus  in  the  sputum  is  conclusive  evidence  of  the 
disease.  In  all  suspected  cases,  the  chest  and  the  expectoration 
should  be  carefully  examined. 

Other  recent  diagnostic  tests  consist  in  the  administration  of 
tuberculin,  the  Calmette  ophthalmo-reaction,  and  the  agglutination 
and  serum  tests.  In  the  tuberculin  test,  %  mgm.  of  old  tuberculin 
is  injected  subcutaneously ;  and  if  no  reaction  occurs  a  larger  dose  of 
I  mgm.  is  given;  and  should  the  result  be  still  negative  a  third  dose 
of  3  or  5  mgm.  is  administered  after  two  or  three  days.  Within 
ten  to  twelve  hours  the  reaction  occurs  with  a  rise  of  temperature 
to  i02°  or  io4°F.  In  Calmette's  reaction,  sl  drop  of  a  ^^  to  i  per  cent, 
solution  of  tuberculin  is  put  on  the  conjunctiva;  in  infected  indi- 
viduals the  conjunctiva  becomes  hyperemic.  Von  Pirquet  's  test  is  a 
vaccination  of  the  skin  under  a  drop  of  25  per  cent,  old  tuberculin  in 
saline  solution;  a  small  papule  in  twenty-four  hours  denotes  the 
reaction. 

Prognosis. — Generally  speaking,  the  outlook  is  very  unfavorable. 
The  duration  is  usually  about  two  years,  death  occurring  from  exhaus- 
tion. Many  cases  under  the  influence  of  good  hygiene,  sunshine, 
stimulating  food,  dry  rarefied  atmosphere,  and  appropriate  treat- 
ment of  every  symptom,  are  prolonged  a  more  or  less  indefinite 
period.  Arrest  of  the  disease,  when  it  occurs,  is  due  to  calcification 
of  the  tubercles.  The  unfavorable  symptoms  are  rapid  pulse,  high 
temperature,  marked  gastric  disturbances,  and  manifestations  due 
to  tuberculosis  elsewhere  in  the  body. 


156  FIBROID   PHTHISIS 

FIBROID    PHTHISIS 

Synonyms. — Chronic  interstitial  pneumonia;  cirrhosis  of  the 
lungs;  Corrigan's  disease. 

Definition. — A  hyperplasia  (thickening)  of  the  pulmonary  connect- 
ive tissue,  resulting  in  atrophy  and  degeneration  of  the  vesicular 
structure,  associated  with  bronchial  inflammation;  characterized 
by  cough,  profuse  expectoration  containing  the  bacillus  tuberculosis, 
fever,  emaciation,  and  ultimately  death  by  asthenia. 

Causes. — The  exciting  cause  is  the  tubercle  bacillus,  but  heredity, 
inhalation  of  irritants,  such  as  occurs  in  the  pursuit  of  occupations, 
such  as  stone-cutting,  grinding,  mining,  etc.,  lobar  pneumonia, 
chronic  bronchitis,  alcohoUsm,  syphilis,  and  chronic  nephritis  should 
be  remembered  as  important  etiological  factors. 

Pathological  Anatomy. — The  characteristic  anatomical  feature 
of  this  disease  is  the  marked  development  of  fibrous  tissue  in  addition 
to  the  tuberculous  process  in  the  lung.  Contraction  of  the  fibrous 
tissue  and  shrinking  of  the  affected  lung  result. 

Symptoms. — The  aft'ection  is  extremely  chronic,  beginning  as  a 
bronchial  catarrh,  which  is  worse  in  winter  and  better  in  summer, 
extending  over  a  long  period.  In  the  more  advanced  stages  of  this 
disease,  the  cough  is  more  persistent  and  expectoration  is  more 
copious,  being  made  up  of  a  muco-purulent  material  containing 
tubercle  bacilli.  Later  hectic  fever,  with  night-sweats,  develops,  and 
dyspnea  and  rapid  emaciation  become  manifest.  Edema  of  the 
ankles  is  a  late  sign  and  depends  on  failure  of  the  circulation.  The 
termination  is  eventually  in  death. 

Physical  Signs. — Inspection  reveals  marked  retraction  of  the 
affected  side,  due  to  shrinking  of  the  diseased  lung. 

Percussion  yields  a  dull  note  or  impaired  resonance,  with  scattered 
areas,  over  which  hyper-resonance  or  tympany  may  be  obtained. 

Auscultation  in  the  early  stage  serves  to  elicit  vesiculo-bronchial 
or  harsh^respiration,  associated  with  large  and  small  moist  or  bub- 
bling rales,  but  at  a  later  period  bronchial,  bronchocavernous,  and 
cavernous  breathing,  with  circumscribed  gurgling  rales,  may  be 
heard. 

Diagnosis. — The  distinctive  features  are  the  prolonged  course,  the 
bronchial  catarrh  worse  during  the  winter,  retraction  of  the  lung,  and 
the  presence  of  the  tubercle  bacillus  in  the  sputum. 

Prognosis. — Death  is  the  inevitable  termination  of  this  disease, 


TREATMENT  OF  PULMONARY  TUBERCULOSIS      1 57 

but  the  course  of  the  affection  extends  over  a  period  from  six  to 
twelve  years.  DaCosta,  in  a  study  of  one  hundred  cases  of  "grind- 
er's consumption,"  found  the  average  duration  to  be  about  twelve 
years  from  the  development  of  the  first  symptoms. 

TREATMENT  OF  PULMONARY  TUBERCULOSIS 

Prophylactic  Treatment. — The  presence  of  the  tubercle  bacillus 
in  the  sputum  renders  that  substance  a  source  of  great  danger  since, 
after  being  dried,  it  is  rapidly  disseminated  throughout  the 
atmosphere.  The  sputum  of  all  tuberculous  patients  should 
therefore  be  thoroughly  disinfected  by  means  of  milk  of  lime,  carbolic 
acid  solution  (i  to  30),  or  caustic  alkalies.  Receptacles  in  which  the 
sputum  is  collected  should  contain  a  small  quantity  of  water  to 
prevent  evaporation,  and  should  be  scalded  in  cleaning.  Paper 
napkins,  pasteboard  spit-cups,  rags,  and  similar  inexpensive  materials 
may  be  used  to  receive  the  expectoration  and  possess  the  great 
advantage  that  they  may  be  destroyed  completely  by  heat.  Spitting 
upon  the  floor  or  in  places  other  than  the  especially  provided  recep- 
tacles should  be  prohibited.  Excessive  drapery  and  superfluous 
upholstery  that  do  not  permit  of  being  easily  cleaned,  should  be 
removed  from  the  apartments  of  the  tuberculous  patient.  The 
possibility  of  infection  by  means  of  milk  and.  meat  should  always 
be  considered.  Infected  meat  and  milk  should  be  rejected 
as  food,  but  an  additional  safeguard  will  be  to  thoroughly 
cook  all  meat  and  boil  all  suspected  milk.  Residence  in  low,  damp, 
shaded  localities  should  be  avoided  by  those  individuals  predisposed 
to  the  disease — fresh  air,  sunshine,  and  out-door  exercise  should  be 
advised.  A  high  altitude  where  the  air  is  dry  and  rare,  and  the 
climate  equable,  is  of  great  advantage  to  such  persons.  Bathing 
and  cold  sponging,  wholesome  diet,  and  moderation  in  eating  and 
drinking,  should  be  prescribed.  Localized  foci  of  the  disease  should 
receive  prompt  attention. 

Climatic  Treatment. — Circumstances  permitting,  all  patients  in 
whom  tuberculosis  is  detected,  should  be  sent  to  a  suitable  climate. 
Those  of  a  robust  type  are  benefited  by  high  altitude  and  cold,  and  a 
certain  degree  of  hardship  or  "roughing  it."  The  change  should  be 
gradual.  Disturbance  of  the  circulatory  system,  cardiac  weakness, 
small  size  of  the  heart,  neurotic  temperament,  and  persistent,  high 
temperature  contraindicate  such  a  change  in  climate.  Those  who 
require  protection  should  seek  a  residence  in  warm  or  equable  and 


158  TREATMENT   OF   PULMONARY   TUBERCULOSIS 

comparatively  dry  places  at  the  sea-level,  or  but  slightly  elevated. 
In  early  cases,  attended  by  persistent,  high  temperature,  a  sea 
voyage  may  be  of  great  benefit.  Colorado  and  New  Mexico  represent 
the  high  and  dry  climates,  while  Southern  California  may  be  taken 
as  the  type  of  warm  and  dry  climates ;  warm  and  moist  climates  are 
encountered  on  the  coast  of  Southern  California  and  in  Florida. 
When  for  any  reason  it  is  impossible  to  move  the  patient  any  dis- 
tance, much  can  be  done  by  placing  the  individual  in  some  nearby 
country  place,  preferably  among  the  hills  and  away  from  damp 
regions.  Plenty  of  fresh  air  and  sunshine  may  then  be  obtained. 
The  city  is  no  place  for  the  consumptive,  but  the  possibility  of  nos- 
talgia and  its  deleterious  effects  should  always  be  considered  when 
ordering  a  change. 

Hygienic  and  Dietetic  Treatment. — The  apartment  in  which  the 
patient  spends  the  greater  portion  of  the  day  should  be  free  from 
dampness  and  so  situated  as  to  be  accessible  to  sunhght  for  as  many 
hours  as  possible.  The  atmosphere  should  not  be  too  dry,  as  cough 
and  subsequent  hemorrhage  may  be  induced  thereby.  The  tempera- 
ture should  average  65°F.  It  is  desirable  that  the  bedroom  be 
occupied  only  at  night,  and  be  well  ventilated  during  the  day.  The 
clothing  should  be  warm  and  loose,  being  changed  with  the  seasons. 
Woolen  or  silk  underwear  should  be  worn  throughout  the  year. 
Heavy,  oppressive  clothing  should  be  avoided.  Frequent  changes 
are  necessary  for  obvious  reasons.  Daily  bathing,  followed  by 
friction,  is  recommended.  Cold  sea-bathing  is  harmful.  Rest  and 
exercise  in  varying  degrees  in  combination  are  beneficial.  Exhaus- 
tion should  always  be  avoided.  Robust  individuals  may  partake  of 
outdoor  exercise  with  benefit,  while  weak  and  anemic  patients  require 
rest  and  passive  movements.  The  presence  of  high  fever  is  always 
an  indication  for  rest.  Exposure  to  sunlight  is  very  beneficial. 
Sedentary  occupations  should  be  avoided.  The  patient  should  be 
constantly  amused.  Nutritious  food,  such  as  meats,  poultry,  game, 
oysters,  fish,  animal  broths,  milk,  eggs,  etc.,  is  always  indicated. 
The  quantity  should  be  liberal.  Nothing,  however,  should  be  fried. 
Among  the  articles  to  be  avoided  may  be  mentioned  pork,  veal,  hot 
bread,  cakes,  pies,  pastry,  sweetmeats,  rich  gravies,  crabs,  lobsters, 
etc.  Water  should  be  taken  freely.  Whiskey,  cod-liver  oil,  and  sto- 
machics aid  the  building  up  of  the  system  and  should  be  given  with 
the  food.  Great  care  should  be  exercised  not  to  discomfort  the 
patient  by  overfeeding. 


TREATMENT    OF   PULMONARY   TUBERCULOSIS  1 59 

Medicinal  Treatment. — Medicines  should  be  administered  for 
their  general  constitutional  effect  and  also  to  relieve  distressing 
symptoms.  Cure,  when  it  is  effected,  is  only  brought  about  by  im- 
proving the  general  health  and  restoring  the  tone  and  resistance  of 
the  body.  To  this  end,  cod-liver  oil,  hypophosphites,  alcohol,  arsenic, 
and  strychnine  should  be  administered  freely.  Plain  cod-liver  oil, 
combined  with  the  hypophosphites  of  calcium,  sodium,  and  potas- 
sium (U.S. P.)  is  an  excellent  preparation;  a  tablespoonful  twice 
daily  is  as  large  a  dose  as  can  be  employed  without  disturbing  the 
stomach.  Should  this  occur,  or  as  is  usually  the  case,  if  there  is 
indigestion  from  other  causes,  nux  vomica,  gentian,  or  other  sto- 
machics should  be  given.  The  following  is  very  beneficial  in  this 
connection : 

I^.     Strychninae  sulphat gr.  iv  0.26  gm. 

Aq.  chloroformi,  vel 

Ess.  pepsini §ij  60.0    c.c. 

M.  S. — Ten  minims  equal  gr.  ^^^4  of  strychnine   (0.0025  gm.). 

Mode  of  administration:  Five  drops  three  times  daily  for  one 
week,  then  10  drops  three  times  daily  for  a  week,  then  15  drops  three 
times  daily  for  a  week,  then  20  drops,  three  times  daily  for  a  week, 
then  15  drops,  then  10  drops,  then  5  drops,  and  so  on  week  after 
week  for  months. 

Whiskey  or  brandy  may  be  given  in  cases  in  which  the  asthenia  is 
at  all  marked,  the  dose  being  guided  by  the  effect  produced  and  the 
exigencies  of  the  individual  case.  A  rise  of  temperature  and  dys- 
pepsia indicate  withholding  the  alcohol.  Arsenic  is  of  great  value 
also  and  may  be  given  in  the  form  of  Fowler's  solution  (not  exceeding 
5  minim  doses),  or  combined  with  digitalis. 

Strychnine  sulphate,  gr.  }io  to  }io  (o.ooi  to  0.002  gm.),  after  meals 
guaiacol,  lUiij  to  v  (0.2  to  0.3  c.c.)  for  adults,  and  TTlij  to  iij  (0.12  to 
0.2  c.c.)  for  children,  four  times  daily,  are  of  value.  Creosote,  gr. 
j  (0.6  gm.)  after  each  meal  gradually  increasing  the  dose,  and  creo- 
sotol,  beginning  with  10  minims  (0.66  c.c),  are  also  beneficial. 
The  inhalation  of  modified  air  (pneumotherapy)  and  atmospheres 
saturated  with  the  vapors  of  iodine,  creosote,  carbolic  acid,  etc.,  have 
been  employed  with  success.  Counter-irritation  of  the  chest  with 
blisters  may  be  considered  in  obstinate  cases. 

Serum  treatment  may  be  accompanied  by  encouraging  results 
in  some  cases.     The  refined  tuberculin  of  Koch  should  be  used  and 


l6o  TREATMENT    OF   PULMONARY   TUBERCULOSIS 

should  be  administered  in  doses  short  of  that  necessary  to  produce 
febrile  reaction.  The  first  dose  should  be  0.00002  mgm.  of  T.R.,  or 
0.000005  of  "the  more  recent  bacillary  emulsion,  and  should  be  given 
hypodermically.  The  earlier  it  is  employed,  the  more  localized  the 
disease,  and  the  less  general  the  infection,  the  greater  will  be  the  pros- 
pect of  good  results  from  its  use.  In  cases  in  which  fever  and  hemor- 
rhage are  present,  it  is  contraindicated.  The  presence  of  mixed  infec- 
tion renders ^it  useless.  The  results  from  its  use  in  the  wards  of  the 
Philadelphia  Hospital  were  Uniformly  negative.  It  is  not  devoid  of 
danger,  and  is  of  most  value  as  a  diagnostic  agent. 

The  cough  of  pulmonary  tuberculosis  when  slight  may  be  readily 
relieved  by  the  application  of  a  mustard  plaster,  capsicum  plaster, 
iodine,  turpentine  stupe,  or  a  fly-blister  to  the  chest  over  the  region 
of  most  distress.  Internally,  creosote,  TTtj  (0.06  c.c),  in  milk  or 
whiskey,  three  times  daily,  gradually  increasing  the  dose,  dilute 
hydrocyanic  acid,  Tflij  to  iv  (0.12  to  0.24  c.c),  terebene,  lUiij  to  x 
(0.18  to  0.62  c.c),  and  similar  expectorants  should  be  administered. 
The  various  preparations  of  opium,  especially  paregoric,  5j  (3-6  c.c), 
morphine,  gr.  ^^4  to  3^  (0.00275  to  0.0165  gm.),  codeine,  gr.  3^ 
(0.0165  gi^O^  and  heroine,  gr.  }/2o  (0.0033  gm.),  are  of  particular  value 
in  relieving  this  symptom. 

I^.     Codeinae  sulphat gr.  H  to  3=-^  0.022  to  o'. 032  gm. 

Acidi  hydrocyanici  dil TTtij                 o.  12                  c.c. 

Syr.  tolu 5j                  4-0                  c.c. 

M.  S. — One  dose,  to  be  given  every  three  hours. 
Or— 

I^.     Codeinae gr.  iv                      o .  26  gm. 

Acid  hydrochlor.  dil 5ss                          2  .0  c.c. 

Spirit,  chloroform! 5iss                        6.0  c.c. 

Syr.  limonis 5j                          30.0  c.c. 

Aq.  lauro-cerasi.  .  .  .q.  s.  ad  5iv              ad   120.0  c.c. 

M.  S. — One  teaspoonful,  repeated  when  cough  is  troublesome. 
Or— 

I^.     Morphin.  sulphat gr.  ss  to  ij     0.33  to  o.  130  gm. 

Potass,  cyanid gr.  iij  0.2  gm. 

Acid,  sulph.  aromat f  5]  to  ij         4.0  to  8.  o  c.c. 

;i    Syrup,  prun.  Virgin,  q.  s.  ad  f^iij  90.0  c.c. 

M.  S. — Tablespoonful  as  often  as  necessary  to  quiet  the  cough 
(Tyson). 

When  coughing  is  harassing  or  expectoration  is  difficult,   as  it 


TREATMENT    OF    PULMONARY    TUBERCULOSIS  l6l 

often  is  in  the  morning,  a  milk  punch  should  be  given  in  preference 
to  any  sedative. 

In  the  pneumonic  variety,  the  attempt  should  always  be  made  to 
remove  the  caseous  matter  by  absorption  and  expectoration.  The 
following  prescriptions  will  sometimes  prove  successful: 

I^.     Ammonii  carb gr.  v  0.3  gm. 

Ammonii  iodidi gr.  v  0.3  gm. 

Aq.  chloroformi 5ij  8.0  c.c. 

Syr.  prun.  Virg 5ij  8.0  c.c. 

M.  S. — Every  five  hours,  diluted. 
Alternating  with — 

I^.     Liq.  potassii  arsenitis TTlv  0.3  c.c. 

Mass.  f erri  carb gr.  v  0.3  gm. 

Vini  xerici f  5j  4-0  c.c. 

Aquae q.  s.  ad  f  §ss  150  c.c. 

Dyspeptic  symptoms  are  nearly  always  present,  but  may  be  aggra- 
vated by  internal  medication,  in  which  cases  the  offending  drugs 
should  be  lessened  in  dose  or  even  temporarily  suspended.  These 
manifestations  should  be  treated  on  general  principles,  the  following 
formulas  will  often  be  found  of  benefit: 

I^.      Pepsini  cryst gr.  ij  o.  13  gm. 

Acidi  hydrochlorici  dil TTlxv  i  .0    c.c. 

Glycerini TTlxx  i .  3    c.c. 

Succi  limonis lUxv  i  .0     c.c. 

Aquae  aurantii  flor..q.  s.  ad  f5ij  ad  8.0    c.c. 

M.  S. — To  be  taken  with  meals,  diluted;  or: 

I^.     Liquor,  potassii  arsenitis.  .  .    Tflxxx  2.0  c.c. 

Tincturae  nucis  vomicae . . .  .    f  5  j  4  •  o  c.c. 

Aquae  chloroformi ad  f  §  ij  ad    60 .  o  c.c. 

M.  S. — 'Teaspoonful  before  meals,  diluted. 

Fever  may  be  materially  lessened  by  rest  alone,  but  in  the  event 
of  its  failing  to  do  so,  cool  sponging  or  the  use  of  phenacetine  or 
antipyrine  will  be  necessary. 

The  following  is  effectual  (but  as  a  rule  quinine  should  be  avoided) : 

I^.     Quininae  sulphat gr.  x  0.6  gm. 

Quininae  hydrochlorid gr.  x  0.6  gm. 

Pulv.  opii  et  ipecac gr.  iij  0.2  gm. 

M.     Ft.  capsul.  No.  ij. 

S. — One  capsule  five  hours  and  the  other  three  hours  before 
the  expected  rise  of  temperature. 
II 


1 62  "■■  LEPROSY 

Night-sweats  are  especially  troublesome  and  may  be  relieved  to  a 
great  extent  by  the  administration,  at  bed-time,  of  atropine  sulphate, 
gi"-  Hoo  "to  }io  (0.00066  to  o.ooii  gm.),  agaric  acid,  gr.  3^  to  3^ 
(0,0082  to  0.0165  gm.),  camphoric  acid,  gr.  xx  to  xxx  (1.32  to  2  gm.), 
picrotoxin,  gr.  }4o  (o.ooii  gm.),  or  aromatic  sulphuric  acid,  gtt.  x  to 
XX  (0.6  to  1.3  c.c).  Sponging  of  the  body  at  bed-time  with  astrin- 
gent solutions,  such  as  the  solution  of  alum  and  solution  of  white 
oak  bark,  or  with  alcohol,  is  beneficial,  Tyson  recommends  a 
lotion  of  balsam  of  Peru,  i  part;  formic  acid,  5  parts;  chloral  hydrate, 
5  parts;  trichloracetic  acid,  i  part;  absolute  alcohol,  100  parts. 

Diarrhea  in  the  course  of  phthisis  is  greatly  benefited  by  the  admin- 
istration of  bismuth  subnitrate,  gr.  xx  (1.3  gm.),  every  three  or  four 
hours,  with  rest  in  bed  and  mustard  to  the  abdomen.  The  following 
may  be  used: 

I^.     Cupri  sulphat gr.  jss  o.i  gm. 

Ext.  nucis.  vomicae gr.  iij  0.2  gm. 

Pulv.  opii gr.  vj  0.4  gm. 

M.     Ft.  pil.  No.  xii. 
S. — One  every  four  hours. 
Or— 

I^.     Liq.  potass,  arsenit ti^xxx  2.0  c.c. 

Tr.  opii  deodorat f  Sjss  6.0  c.c. 

Liq.  pepsini q.  s.  ad  f  Sij  60.0  c.c. 

M.  S. — Teaspoonful  at  each  meal. 

Hemoptysis  is  best  treated  by  absolute  rest,  with  the  application 
of  an  ice-bag  to  the  chest  and  the  administration  of  morphine,  gr. 
3^  (0.016  gm.)  hypodermically .  Of  almost  equal  value  are  atropine 
sulphate,  gr.  3^00  to  Ho  (0.00032  to  o.ooi  gm.),  and  spirits  of  glo- 
noin  (nitroglycerin),  TUj  (0.06  C.c).  Gallic  acid,  salt,  ergot,  gelatin, 
and  suprarenal  extract  are  also  recommended.  If  the  hemorrhage 
is  profuse  the  extremities  should  be  circularly  constricted  by  hga- 
tures.  The  various  measures  usually  advised  for  internal  hemor- 
rhage under  other  circumstances  are  appHcable. 

Pains  in  the  chest  are  rather  common.  Strapping  of  the  chest, 
mild  counter-irritation,  or  morphine  hypodermically,  will  be  required, 
according  to  their  severity. 

LEPROSY 

SynonyTn. — Elephantiasis  Graecorum. 

Definition. — A   chronic   infectious   disease,   due  to   the   bacillus 


LEPROSY  163 

leprae,  characterized  by  nodules  in  the  skin  and  mucous  membranes 
{tubercular  leprosy) ;  also  by  infiltration  of  the  nerve  trunks  {anesthetic 
leprosy)]  perversion  of  sensation  and  progressive  mutilation  may 
follow. 

Etiology. — The  specific  cause  is  the  bacillus  leprae,  which  closely 
resembles  the  tubercle  bacillus;  how  it  is  transmitted  is  not  settled. 
Contagion,  heredity,  inoculation,  diet,  the  air,  and  intermediate 
hosts  (mosquitoes,  fleas,  and  bed-bugs),  have  all  been  considered 
etiological  factors. 

The  following  are  the  conclusions  of  the  Indian  Leprosy  Commis- 
sion: 

1.  Leprosy  is  a  disease  sui  generis,  and  not  a  manifestation  of 
syphilis  or  tuberculosis. 

2.  It  is  not  hereditary. 

3.  It  must  be  regarded  as  contagious  and  inoculable. 

4.  It  is  not  originated  by  food,  climate,  or  insanitary  surroundings, 
but  these  causes  may  predispose  to  the  disease. 

5.  The  method  of  origination  is  unknown. 

Morbid  Anatomy. — The  typical  lesion  is  a  nodule  in  the  skin 
or  mucous  membrane.  This  is  of  variable  size,  consisting  of  epithe- 
lioid, lymphoid  and  giant  cells  in  a  connective  tissue  stroma,  within 
and  between  which  the  bacilli  may  be  found.  The  nodule  is  vascular, 
thus  differing  from  the  tubercle.  The  bacilli  may  also  be  found  in 
the  peripheral  nerve  fibers  in  the  anesthetic  variety.  The  face, 
hands  and  feet  may  be  terribly  disfigured,  the  phalanges  may  drop 
off,  and  the  internal  organs  become  the  sites  of  nodular  formation; 
the  lungs,  Hver  and  spleen  being  specially  involved.  The  nerves 
most  frequently  involved  are  the  facial,  median,  ulnar,  radial,  poster- 
ior, tibial  and  peroneal. 

Diagnosis. — This  is  made  by  finding  the  specific  bacillus.  The 
diagnosis  of  typical  cases  presents  no  difficulty  to  those  who  have 
seen  lepers. 

Prognosis  and  Treatment. — The  disease  is  incurable,  but  the 
patient  may  live  a  very  long  time.  Segregation  should  be  insisted 
on.  The  most  useful  remedy  is  probably  Chaulmoogra  oil;  this  is 
given  by  inunction  over  the  affected  areas,  and  also  internally.  It 
should  be  rubbed  in  twice  a  day,  and  given  in  capsules  by  the  mouth, 
beginning  with  10  minims,  and  gradually  increasing  till  the  digestion 
is  disturbed,  when  the  dose  must  be  reduced  for  a  time.  This  must 
be  persisted  in  for  a  long  time.     At  the  same  time  the  general  health 


164  GXANDULAR   FEVER 

must  be  attended  to  and  fresh  air,  exercise,  tonics  and  suitable  diet 
must  be  insisted  on.  Sodium  chloride  in  the  food  is  said  to  be  injur- 
ious to  the  bacilli.  Other  remedies  that  have  been  used  are  gurjun 
oil,  potassium  iodide,  creosote,  and  salicyUc  acid. 

GLANDULAR  FEVER 

Definition. — An  acute  infectious  disease,  generally  occurring  in 
childhood,  and  characterized  by  sudden  onset,  moderate  fever, 
swelling  of  the  cervical  lymphatic  glands,  and  constipation;  but 
there  is  no  rash.     It  is  probably  contagious. 

Etiology. — The  cause  is  unknown.  The  infectious  agent,  whatever 
it  may  be,  is  said  to  enter:  (i)  through  the  tonsils  or  pharynx,  or  (2) 
by  way  of  the  intestines.  Predisposing  causes  are:  winter  months, 
previous  illness,  lowered  vitality,  and  general  malnutrition. 

Symptoms. — The  incubation  period  is  about  five  to  eight  or  ten 
days,  and  is  without  symptoms.  The  acute  symptoms  appear 
suddenly;  there  are  pain  and  tenderness  in  the  neck,  and  these  are 
made  worse  by  mov^ement  of  head  or  neck  and  by  swallowing;  fever 
occurs  early,  it  is  remittent,  and  not  severe,  running  to  about  101°  or 
io3°F.  The  face  may  be  flushed,  but  there  is  no  rash.  There  may 
be  nausea,  anorexia,  vomiting,  and  abdominal  pain.  The  throat 
and  pharynx  show  inflammation,  and  there  is  some  dysphagia.  The 
lymphatic  glands  are  enlarged,  and  some  of  them  can  be  palpated, 
particularly  those  in  the  cervical  and  carotid  regions,  just  below 
and  near  the  anterior  border  of  the  sterno-mastoid.  The  posterior 
cervical,  axillary  and  inguinal  glands  may  also  be  affected;  and 
abdominal  tenderness  with  enlarged  Hver  and  spleen  will  then  be 
noticed.  The  fever  abates  as  the  gland  involvement  reaches  its 
height,  and  the  latter  may  last  twelve  or  fourteen  days,  while  the 
fever  remains  only  three  or  four  days. 

Complications. — The  most  serious  complication  is  nephritis; 
suppuration  of  the  glands  is  not  very  common;  otitis  media  and 
retropharyngeal  abscess  may  also  occur.  In  severe  cases  the  begin- 
ning of  convalescence  is  often  marked  by  the  passage  of  thin  greenish 
stools,   containing  mucus. 

Diagnosis. — This  is  to  be  made  from  the  symptoms,  particularly 
the  cervical  adenitis;  the  diseases  to  be  excluded  are  pharyngitis, 
tonsillitis,  parotitis,   and  leukemia. 

Prognosis  is  favorable,  except  when  the  case  is  complicated  by 
nephritis. 


MILK    SICKNESS  165 

Treatment. — This  is  almost  entirely  symptomatic.  Isolation 
should  be  insisted  on  so  as  to  prevent  the  spread  of  the  disease.  Rest 
is  necessary;  the  pain  may  be  relieved  by  hot  applications;  iron,  cod 
liver  oil,  light  but  nutritious  food,  and  general  hygienic  precaution 
are  all  indicated.  Calomel  in  small  doses  has  been  recommended, 
and  also  condemned.  For  the  adenitis,  applications  of  belladonna 
should  be  made;  and  when  the  fever  is  high  (in  the  early  stage  of  the 
disease)  or  the  pain  is  severe,  sodium  salicylate  may  be  given.  If 
the  glands  suppurate,  incision  and  drainage  will  be  in  order. 

ROCKY  MOUNTAIN  SPOTTED  FEVER 

Definition. — An  acute  infectious  disease  occurring  in  Montana, 
Idaho,  Nevada  and  Wyoming,  and  characterized  by  chills,  fever, 
muscular  pains,  headache  and  a  maculopapular  or  petechial  eruption. 

Cause. — This  is  unknown;  but  the  disease  is  spread  by  the  bite 
of  a  tick,  Dermaceutor  occidentalis. 

Sjnnptoms. — Most  cases  develop  in  the  early  spring,  and  are 
marked  by  a  brief  period  of  malaise,  followed  by  chills,  fever,  head- 
ache, and  pains  in  bones,  joints,  and  muscles.  On  about  the  third 
to  the  sixth  day  a  maculopapular  or  petechial  rash  appears;  it  is 
generally  most  marked  about  the  hands  and  feet,  but  may  occur  on 
the  face  and  trnuk. 

Diagnosis. — This  is  made  by  the  location,  time  of  year,  and  a 
history  of  a  tick  bite.  It  is  to  be  diagnosed  from  typhoid,  typhus, 
dengue,  cerebrospinal  meningitis;  but  the  characteristics  of  these 
diseases  are  so  marked  that  differentiation  should  not  be  difficult. 

Treatment. — Protection  against  tick  bites  is  of  the  utmost  impor- 
tance.    Cold  sponging,  quinine,  and  later  tonics,  are  indicated. 

MILK  SICKNESS 

Synon3mis. — Trembles;  puking  fever. 

Definition. — An  infectious  disease,  occurring  chiefly  in  the  western 
and  southwestern  States,  and  acquired  from  cattle  suffering  from  the 
"trembles." 

Etiology. — Unknown. 

Symptoms. — Restlessness  and  malaise  are  usually  the  prodromal 
symptoms.  After  two  or  three  days  the  patient  suffers  severe 
epigastric  pain,  with  nausea,  vomiting,  and  constipation;  there  may 


1 66  ACUTE    FEBRILE   JAUNDICE 

be    fever    of  moderate  or  high  degree,  and  muscular  tremors  are 
noticeable. 

Prognosis. — The  disease  is  either  short  and  fatal,  or  recovery  may 
occur  after  a  prolonged  convalescence. 

Treatment. — This  is  symptomatic,  and  consists  mainly  of  food  and 
tonics.  Care  should  be  taken  to  avoid  the  use  of  infected  food  and 
milk. 

ACUTE  FEBRILE  JAUNDICE 

SynonyTn. — Weil's  disease. 

Definition. — An  acute  infectious  disease,  characterized  by  fever, 
jaundice,  muscular  pain,  and  enlarged  liver  and  spleen. 

Etiology. — Unknown.  The  latest  view  is  that  the  disease  is  caused 
by  a  spirochete — the  Spirochceta  nodosa.  It  occurs  in  the  summer 
months,  and  attacks  men  in  preference  to  women;  butchers,  brewers, 
and  alcoholics  are  particularly  liable  to  the  disease. 

Symptoms. — The  illness  begins  suddenly  with  a  chill,  fever  (102°  to 
i04°F.),  and  epigastric  pain;  jaundice,  headache,  and  muscular 
pains  soon  follow;  the  stools  are  apt  to  be  clay-colored;  a  rapid  pulse 
is  quite  common,  and  herpes  is  frequently  noted;  the  liver  and  spleen 
are  enlarged. 

Treatment. — General  symptomatic  treatment  is  indicated:  calo- 
mel, salines,  and  cold  water  enemata  are  beneficial;  heat  and  massage 
with  chloroform  liniment  may  help  the  muscular  pains. 

CONSTITUTIONAL  DISEASES 

CHRONIC  ARTICULAR  RHEUMATISM 

Causes. — The  affection  may  follow  an  acute  or  subacute  attack, 
but  in  most  cases  it  is  chronic  from  the  very  beginning.  It  is  ob- 
served usually  in  the  poor,  past  middle  life,  and  is  influenced  greatly 
by  continued  exposure  to  cold  and  wet  and  by  heredity. 

Pathological  Anatomy. — Thickening  of  the  capsule  and  ligaments 
of  the  joints  and  the  adjacent  fibrous  structures  is  a  marked  feature. 
In  some  cases  the  cartilages  are  eroded.  Muscular  atrophy  and 
neuritis  are  observed  as  the  condition  progresses.  These  changes 
result  in  impairment  of  motion  and  false  ankylosis. 

Sjrmptoms. — The  principal  symptoms  are  pain  and  stiffness  in  the 
joints  aggravated  by  stormy  weather.  Tenderness  and  slight  swell- 
ing may  be  present  during  the  exacerbations.     In  most  cases  the 


MUSCULAR   RHEUMATISM  1 67 

condition  is  polyarticular.  As  the  disease  progresses  the  joint  move- 
ment may  be  seriously  impaired  or  even  lost  entirely  and  the  joints 
greatly  distorted.  Except  in  cases  attended  by  severe  pain  of  long 
duration,  the  general  health  may  not  be  seriously  impaired.  The 
affection  resists  treatment  and  tends  to  persist  indefinitely  but  does 
not  endanger  life. 

Treatment. — The  symptoms  may  be  relieved  to  a  great  extent  by 
judicious  treatment  but  there  is  no  curative  treatment.  Iodide  of 
potassium,  guaiac,  iron,  arsenic,  and  similar  tonics  should  be  adminis- 
tered. Residence  in  a  dry  and  warm  climate  is  particularly  beneficial. 
The  Turkish  bath  and  bathing  in  the  hot  alkaline  waters  (Hot  Springs 
of  Virginia  or  Arkansas)  are  valuable. 

Locally,  counter-irritation  by  means  of  the  Paquelin  cautery,  or 
blisters,  massage,  electricity,  and  hot-air  baths  are  very  useful. 
Rubefacient  liniments  and  absorbent  ointments  may  also  be  em- 
ployed. 

MUSCULAR  RHEUMATISM 

Synon3mis. — Myalgia;  and  according  to  location:  cephalodynia; 
lumbago;  torticollis;  pleurodynia. 

Definition. — An  affection  of  the  voluntary  muscles,  inflammatory 
in  character,  either  acute  or  chronic;  characterized  by  pain,  tender- 
ness, and  stiffness  of  the  affected  muscles.  It  is  never  complicated 
with  cardiac  disease. 

Causes. — A  disease  of  adult  life.  One  attack  predisposes  to 
another.  Almost  always  due  to  cold  or  damp,  or  direct  draught  of 
cold  air.     Gout  increases  the  tendency  to  attacks. 

Pathological  Anatomy. — The  true  nature  of  muscular  rheumatism 
is  not  yet  determined.  Virchow  suggests  a  "hyperemia  of,  and 
scanty  serous  exudation  between,  the  muscular  striae,  in  chronic 
cases  inflammatory  proliferation  of  the  connective  tissue." 

Symptoms. — The  first  attack  is  generally  acute,  and  its  onset  is 
rather  sudden  with  pain,  slight  tenderness,  and  stiffness  of  the 
affected  muscles,  increased  by  any  attempt  at  movement.  These 
symptoms  may  be  constant  or  may  only  be  brought  out  on  motion. 
Spasmodic  contraction  and  rigidity  of  the  muscles  may  be  present. 
Fever  is  absent  and  there  are  no  objective  symptoms.  The  acute 
form  seldom  lasts  more  than  a  week;  the  chronic  variety  recurs 
frequently  especially  with  changes  in  the  weather,  and  may  become 
constant. 


1 68  MUSCULAR   RHEUMATISM 

Varieties. — It  may  affect  any  or  all  of  the  voluntary  muscles,  but 
its  most  frequent  and  important  varieties  are: 

1.  Cephalodynia. — Situated  in  the  occipito-frontal  muscles.  Dis- 
tinguished from  neuralgia  of  the  trifacial  or  occipital  nerve,  by  pain 
on  both  sides  of  the  head,  excited  or  aggravated  by  the  movements 
of  the  muscles  and  by  absence  of  disseminated  points  of  tenderness. 
The  muscles  of  the  eye  may  be  affected,  and  movements  of  that  organ 
excite  pain.  If  the  temporal  and  masseter  muscles  are  attacked, 
mastication  induces  pain. 

2.  Torticollis.- — -Wry  neck,  or  stiff  neck.  Situated  in  the  sterno- 
mastoid  muscles.  Generally  limited  to  one  side  of  the  neck,  toward 
which  side  the  head  is  twisted,  great  pain  being  excited  on  attempt- 
ing to  turn  to  the  opposite  side.  Rheumatism  of  the  muscles  of 
the  back  of  the  neck,  cervicodynia,  may  be  mistaken  for  occipital 
neuralgia. 

3.  Pleurodynia. — Situated  in  the  thoracic  muscles,  and  may  be 
mistaken  for  pleuritis,  or  intercostal  neuralgia,  from  which  it  is 
differentiated  by  the  absence  of  the  diagnostic  features  of  each. 
Pain  is  excited  by  forced  breathing,  coughing,  and  sneezing. 

4.  Lumbago  or  Lumhodynia. — Situated  in  the  mass  of  muscles 
and  fascia,  which  occupy  the  lumbar  region.  This  is  the  most 
common  variety;  and  usually  affects  both  sides.  It  may  set  in 
rapidly,  and  become  very  severe.  Motion  of  any  kind  aggravates 
the  pain,  which  often  becomes  very  sharp  or  stabbing  in  character. 
It  is  sometimes  complicated  with  acute  sciatica,  when  the  suffering 
is  agonizing. 

Prognosis. — Death  never  results  from  this  condition.  The  attacks 
may  be  relieved  by  prompt  and  appropriate  treatment,  but  the 
rheumatic  tendency  is  often  difficult  to  eradicate. 

Treatment. — Rest  is  the  first  indication.  This  is  accomplished 
in  pleurodynia  by  firmly  strapping  the  affected  side  with  broad 
strips  of  plaster,  extending  from  mid-spine  to  mid-sternum. 

The  local  application  to  the  affected  muscles  of  hot  poultices, 
made  of  two-thirds  pilocarpus  leaves  and  one-third  flaxseed  meal, 
changing  them  every  two  hours,  is  the  most  rapidly  successful  treat- 
ment in  acute  cases. 

In  all  cases,  the  internal  administration  of  antipyrine,  gr.  x  to  xx 
(0.6  to  1.3  gm.),  sodium  salicylate,  gr.  xv  to  xx  (i  to  1.3  gm.),  or 
lithium  bromide,  gr.  v  to  xxx  (0.324  to  1.944  gm.),  every  three  hours 


ARTHRITIS   DEFORMANS  1 69 

is  of  great  benefit.  When  there  is  great  pain  and  consequent  insom- 
nia the  following  should  be  used: 

I^.     Pulv.  ipecac,  et  opii gr.  x  0.6  gm. 

Potass,  nitfat gr.  v  to  x  o .  3  to  o .  6  gm. 

M.  S. — In  powder,  morning  and  night. 

Or  morphine  sulphate,  gr.  }^  to  34  (0.008  to  0.016  gm.),  and  atropine 
sulphate,  gr.  3^0  (0.0008  gm.),  should  be  injected  directly  into  the 
affected  muscles  and  repeated  as  the  occasion  requires.  When  the 
disease  is  limited  to  a  few  muscles  the  following  liniment  is  valuable: 

I^.     01  gautheriae 5jss  6  c.c. 

Spirit,  vini  rectif f  gij  60  c.c. 

M.  S. — Thoroughly  rub  into  affected  part. 

In  all  forms,  btit  more  particularly  in  lumbago,  a  few  dry  cups  or 
blisters  over  the  seat  of  pain  will  afford  immediate  relief.  Other 
measures  of  value  are  dry  heat  such  as  a  warm  flat-iron,  hot-air  baths, 
massage,  electricity,  and  acupuncture. 

In  chronic  cases,  the  administration  of  potassium  iodide,  guaiac, 
sulphur,  arsenic,  or  gelsemium  in  various  combinations  is  recom- 
mended. The  bowels  should  be  kept  regular,  preferably  by  the  use 
of  salines.  The  local  treatment  is  similar  to  that  of  the  acute  form, 
being  modified  to  suit  the  individual  case. 

ARTHRITIS  DEFORMANS 

Synonjnn. — Rheumatoid  arthritis. 

Definition. — A  destructive  disease  of  the  joints,  attended  by 
destructive  changes  in  the  synovial  membranes,  cartilages,  and  bone, 
by  osseous  formations  about  the  articulations,  loss  of  motion,  and 
deformity. 

Causes. — The  etiology  is  doubtful.  It  occurs  most  often  in  middle- 
aged  women.  Among  the  predisposing  causes  may  be  mentioned 
heredity,  bad  hygiene,  exposure,  injury,  prolonged  lactation,  fre- 
quent pregnancies,  menopause,  grief,  mental  anxiety,  tuberculosis, 
and  frequent  attacks  of  acute  articular  rheumatism.  It  is  considered 
a  trophoneurosis  by  some  observers,  and  by  others  to  be  of  infectious 
origin. 

Pathological  Anatomyt — At  first  the  affection  is  attended  by 
hyperemia  of  the  synovial  membrane  and  increase  of  the  synovial 


1 70  ARTHRITIS    DEFORMANS 

fluid.  This  is  followed  by  proliferation  of  its  cells  with  the  subse- 
quent formation  of  villous  or  nodular  outgrowths.  The  capsular 
membrane  becomes  irregularly  thickened  and  the  synovial  fluid 
decreases.  As  the  process  progresses  the  Hgaments  become  de- 
stroyed, thus  permitting  dislocation.  The  interarticular  fibrocarti- 
lages  become  ulcerated  and  disappear  as  do  the  cartilages  covering  the 
ends  of  the  bones,  thus  exposing  the  articular  extremities  of  the  bones 
which  become  smooth,  eburnated,  and  greatly  enlarged.  The  villous 
nodules  become  ossified  and  the  periosteum  forms  new  bone.  The 
adjacent  ligamentous  and  fibrous  structures  become  greatly  thick- 
ened. Stiffness  and  impairment  of  motion  are  produced  at  first 
but  later  ankylosis  (false),  immobility,  and  deformities  result. 
The  surrounding  muscles  atrophy  and  neuritis  is  not  infrequent. 

Symptoms. — The  affection  may  be  acute  or  chronic.  In  the  acute 
variety  several  joints  are  attacked  at  the  same  time  and  slight 
pyrexia  is  present.  The  affected  joints  are  swollen  and  painful  but 
other  acute  inflammatory  phenomena  are  absent.  The  attack  sub- 
sides more  or  less,  to  recur  after  a  varying  interval. 

The  chronic  form  usually  attacks  but  one  joint  at  first,  beginning, 
as  a  rule,  in  one  of  the  metacarpo-phalangeal  articulations.  The 
joint  slowly  enlarges  and  becomes  painful,  neuralgic  pains  being 
excited  by  any  attempts  at  movement.  As  the  disease  progresses 
the  wrists,  ankles,  elbows,  knees,  jaws,  and  spine  are  involved,  the 
corresponding  joints  on  each  side  of  the  body  being  affected  simul- 
taneously. Movement  is  greatly  impaired  and  soon  the  articulations 
become  rigid.  Crepitation  is  distinct  after  ulceration  has  destroyed 
the  cartilage.  Redness  and  tenderness  are  absent  but  swelling  is 
marked.  The  muscles  waste,  thereby  giving  the  joints  the  appear- 
ance of  greater  hypertrophy.  Deformity  soon  manifests  itself  due 
to  the  disappearance  of  the  cartilages  and  to  contractures  of  the 
muscles.  The  fingers  are  bent  backward  and  drawn  toward  the 
ulnar  side.  The  patient  lies  with  the  thighs  and  legs  drawn  up  in 
adduction.  Occasionally  there  is  effusion  into  the  joints.  In  addi- 
tion to  pain  there  may  be  tingling,  numbness,  local  sweating,  and 
pigmentation  of  the  skin.  The  disease  tends  to  advance  slowly, 
ultimately  involving  all  the  joints  and  rendering  the  patient  a  help- 
less invalid. 

Heberden's  nodosities  are  the  nodules,  encountered  in  this  disease, 
on  the  sides  and  ends  of  the  distal  phalanges  of  the  fingers  and  toes. 
They  occur  most  often  in  middle-aged  women.     They  may  be  the 


ARTHRITIS   DEFORMANS  171 

seat  of  pain  and  tenderness,  especially  when  the  parts  are  cold  or 
injured.  Subjects  having  these  nodules  seldom  have  invasion  of 
the  large  joints.     Similar  nodules  are  sometimes  observed  in  gout. 

Diagnosis. — Chronic  articular  rheumatism  is  often  confounded 
with  rheumatoid  arthritis;  but  the  former  lacks  the  marked  struc- 
tural changes  and  the  progressive  involvement  of  joint  after  joint. 

Gout  differs  from  rheumatoid  arthritis  by  the  presence  of  deposits 
of  urate  of  sodium  in  the  joints,  the  ears,  tips  of  fingers,  and  the 
bursae  over  the  olecranon  process  of  the  elbow,  the  presence  of  uric 
acid  in  the  blood,  and  the  decided  history  of  acute  paroxysms. 

Gonorrheal  rheumatism,  so-called,  has  symptoms  akin  to  rheumatoid 
arthritis,  but  the  history  of  urethral  discharge  clears  up  the  diagnosis. 

Paralysis  agitans,  when  pronounced,  might  be  confounded  with 
rheumatoid  arthritis  if  the  examination  were  limited  to  the  joints; 
but  the  whole  history,  such  as  the  tremor,  the  gait,  etc.,  should 
prevent  error. 

Prognosis. — If  early  treatment  be  instituted,  the  disease  may  be 
held  in  abeyance  for  several  years.  After  pronounced  structural 
changes  have  begun,  the  malady  is  incurable,  although  it  may  remain 
stationary  for  a  long  time. 

Treatment. — The  diet  and  hygiene  should  receive  attention,  and 
all  measures  tending  to  improve  the  general  health  should  be  em- 
ployed. Before  serious  structural  changes  have  occurred,  the  rub- 
bing into  the  joint  of  cod-hver  oil  with  the  internal  administration  of 
effervescing  lithium  citrate,  5j  (4  gm.),  three  times  daily  and  the 
following   tonic  mixture  is   of   value: 

I^.     Massas  ferri  carbonat gr.  v  0.3  gm. 

Liquor,  potass,  arsenit TTlv  0.3  c.c. 

Vini  xerici f  5  j  4 .  o  c.c. 

Aquse  destill ; .  .   f  5j  4.0  c.c. 

M.  S. — After  meals,  well  diluted. 

The  internal  administration  of  guaiacol  carbonate,  gr.  v  to  x  (0.3 
to  0.6  gm.),  three  times  daily  together,  with  painting  of  the  joints, 
when  painful,  with  the  following  is  at  times  very  efficient: 

I^.     Guaiacol i  part. 

Tinct.  iodi 6  parts. 

M.  S. — Paint  over  joints  twice  daily. 

Iron,  arsenic,  salicylates,  etc.,  may  also  be  employed.  Massage  is 
often  of  value. 


172  GOUT 

GOUT 

Synonym. — Podagra. 

Definition. — A  constitutional  disease,  usually  inherited;  character- 
ized by  the  sudden  occurrence  of  a  paroxysm  of  severe  pain  and 
swelling  in  one  of  the  smaller  joints — the  great  toe  usually — with  the 
presence  of  uric  acid  in  the  blood,  and  the  deposit  of  the  urate  of 
sodium  in  the  structure  of  the  joint.  When  occurring  in  the  hand,- 
it  has  been  termed  chiragra;  and  when  in  the  knee,  gonagra. 

Causes. — The  attacks  usually  follow  some  dietetic  indiscretion 
such  as  the  overindulgence  in  malt  Hquors  and  sweet  wines,  excessive 
eating,  and  exposure.  Lead-poisoning,  nervous  strain,  sedentary 
habits,  and  slight  injury  are  also  causes.  The  tendency  toward 
gout  is  usually  inherited,  and  men  are  affected  with  greater  frequency 
than  women.  In  the  inherited  variety  there  are  some  manifestations 
early  in  life,  but  in  the  acquired  form  it  seldom  shows  itself  before 
the  age  of  thirty-five. 

Pathological  Anatomy. — The  disease  is  believed  to  be  brought 
about  by  an  excess  of  uric  acid  in  the  blood,  salts  of  which,  particu- 
larly the  urate  of  sodium,  are  deposited  in  the  structure  of  the  small 
joints  and  tissues  that  are  not  very  vascular.  As  these  deposits 
increase  inflammatory  reaction — hyperemia,  redness,  swelling,  and 
effusion  are  produced,  terminating  ultimately  in  ulceration  and 
expulsion  of  chalk-like  masses  of  varying  size.  In  many  cases  the 
deposits  are  retained  for  an  indefinite  period,  becoming  greater  with 
each  attack,  finally  causing  great  deformity  and  stiffness.  The 
metatarsophalangeal  joint  of  the  great  toe  is  usually  first  affected, 
but  the  deposits  also  accumulate  in  the  knuckles,  eyelids,  and  carti- 
lages of  the  ear.  Crystals  of  sodium  urate  may  be  seen  by  the  naked 
eye  in  the  tubules  and  intratubular  structure  of  the  kidneys,  which 
become  small,  granular,  and  fibrous  (gouty  kidney).  Hypertrophy 
of  the  left  ventricle  and  arteriosclerosis  usually  accompany  or  result 
from  this  condition. 

Symptoms. — Acute  gout  is  rare  in  the  United  States.  It  occurs 
in  paroxysms  between  which  are  varying  intervals.  The  paroxysm 
is  usually  preceded,  for  a  few  days,  by  acid  dyspepsia,  constipation, 
headache,  lassitude,  insomnia,  irritability  of  temper,  etc.  The 
attack  in  most  cases  begins  suddenly,  between  midnight  and  2  a.m. 
with  acute  pain  in  the  baU  of  the  great  toe,  which  becomes  red,  hot, 
swollen,  and  so  sensitive  that  the  sHghtest  touch  is  intolerable.     The 


GOUT 


173 


veins  are  filled,  the  foot,  ankle,  and  leg  swollen,  and  the  limb  the 
seat  of  sudden  spasmodic  contractions,  which  increase  the  suffering; 
slight  relief  is  afforded  by  elevating  the  limb.  Associated  with  the 
local  symptoms  are  chill,  fever,  quickened  pulse,  thirst,  coated  tongue, 
constipation,  and  scanty,  acid,  high-colored  urine,  which  deposits, 
on  cooling,  a  heavy  brickdust  sediment.  Toward  daylight  the 
symptoms  ameliorate  to  return  again  at  sundown,  the  severity 
gradually  lessening  until  the  fourth  or  fifth  day,  when  convalescence 
is  estabUshed,  the  patient,  as  a  rule,  feeling  better  than  before  the 
attack. 

Retrocedent  gout  is  the  term  used  to  indicate  those  cases  in  which 
the  symptoms  suddenly  disappear  in  the  joints  and  are  followed 
by  alarming  gastric,  cardiac,  or  cerebral  manifestations. 

Chronic  gout  results  from  a  repetition  of  acute  attacks,  and  in 
typical  cases  the  deposits  may  be  detected  in  the  various  regions 
in  which  they  are  prone  to  occur  with  stiffness  and  varying  grades 
of  deformity  in  the  smaller  joints.  Constitutional  symptoms  are 
present,  but  to  a  milder  degree.  Paroxysms  are  apt  to  occur  at  any 
time,  but  develop  slowly  with  less  pronounced  symptoms. 

Diagnosis. — The  history,  mode  of  life,  age,  acute  onset,  location, 
and  the  presence  of  the  deposits  (tophi)  will  serve  to  distinguish  the 
affection  from  acute  articular  rheumatism  and  rheumatoid  arthritis, 
with  which  it  may  at  times  be  confounded.  The  following  table  from 
Gould  and  Pyle's  Cyclopedia  of  Medicine  and  Surgery  will  also  help: 


Gout 


Rheumatism 


1.  Chiefly  affects  small  joints. 

2.  More  pain,  redness,  and  edema. 

3.  Moderate  fever — 101°. 

4.  Sweats  not  profuse. 

5.  Pain  more  periodic. 

6.  Cuticle  desquamates. 

7.  Often  recurs  at  regular  intervals. 


1.  Affects  larger  joints. 

2.  Parts  swollen  but  less  painful. 

3.  High  fever — 104°. 

4.  Profuse  acid  sweats. 

5.  Pain  continuous. 

6.  Cuticle  usually  intact. 

7.  Time  of  recurrence  indefinite. 


Prognosis. — Acute  gout  is  rarely  fatal,  but  is  prone  to  recur. 
Chronic  gout  is  less  favorable.  The  kidney,  arterial,  and  cardiac 
complications  materially  shorten  life.  Acute  diseases  or  injuries 
occurring  in  the  course  of  chronic  gout  are  more  serious  than  under 
other  circumstances. 

Treatment. — In  the  acute  attack,  wine  of  colchicum  root,  gtt. 
XV  to  XXX  (i  to  2  C.C.),  well  diluted,  should  be  given  immediately 


174  GOUT 

and  repeated  every  two  hours  until  relief  is  afforded  or  the  physiolog- 
ical limit  reached.  It  may  be  combined  with  sodium  salicylate, 
gr.  XX  (1.3  gm.),  every  two  hours.  The  bowels  should  be  opened 
by  the  administration  of  a  course  of  calomel,  followed  by  a  sahne. 
Water,  especially  the  alkaline  waters,  should  be  freely  consumed. 
The  diet  should  be  liquid,  preferably  milk.  Bartholow  recommends 
the  following  pill: 

I^.     Colchicinse. .   gr.  ^40  0.0013  S^- 

Ext.  colocynth.  comp gr.  ss  o .  032    gm. 

Quini,nse  sulphat gr-  iij  o  •  2        gm. 

M.     Ft.  pil.  No.  j. 

S. — One  such  pill  to  be  taken  every  three  hours. 

The  pain  will  call  for  the  use  of  the  coal-tar  products  and  morphine, 
but  the  latter  should  be  used  with  caution  on  account  of  the  possible 
kidney  complications.  The  affected  part  should  be  elevated  and 
dressed  with  cloths  soaked  in  lead- water  and  laudanum. 

For  subacute  or  lingering  cases  potassium  iodide,  alone  or  in  com- 
bination, as  the  following,  is  of  value : 

I^.     Potassii  iodidi 3ij  8  gm. 

Vini  colchici  radicis f  5iv  15  c.c. 

Aquae  destil f  Bijss  75  c.c. 

M.  S. — Teaspoonful,  well  diluted,  after  meals  and  at  bed- time. 

In  chronic  gout  the  diet,  habits,  mode  of  life,  etc.,  should  be  sub- 
jected to  considerable  regulation.  As  far  as  practicable  all  nitro- 
genous or  albuminous  substances  should  be  interdicted.  The  patient 
should  be  forbidden  pastry,  hot  bread,  cakes,  sweet-meats,  spices, 
condiments,  veal,  liver,  mutton,  lamb,  pork,  cheese,  tomatoes,  beans, 
oatmeal,  sugar,  tea,  coffee,  wines,  and  malt  liquors.  The  foods  per- 
missible include  milk,  butter,  oysters,  fish,  vegetables,  and  acid  fruits, 
such  as  strawberries,  lemons,  and  oranges. 

The  free  use  of  water,  particularly  alkaline  waters,  such  as  Buffalo 
lithia,  Farmville  lithia,  or  Saratoga  vichy,  should  be  encouraged. 
The  administration  of  effervescing  citrate  of  lithium,  5j  (4  gm.), 
in  water  three  times  daily,  and  of  the  saline  laxatives  is  also  of  value. 
The  underclothing  should  be  woolen,  and  it  is  advisable  for  the 
patient  to  seek  a  residence  in  a  warm  climate.  Exercise  and  massage 
are  of  great  importance  in  the  treatment.  Hydrotherapeutic 
measures — cold  bathing,  Turkish  bath,  etc. — when  cautiously  em- 
ployed, are  of  great  value. 


RICKETS  175 

The  medicinal  treatment  includes  the  use  of  the  alkaline  carbonates, 
colchicum,  salicylates,  potassium  iodide,  guaiac,  and  tonics,  such 
as  iron,  quinine,  strychnine,  and  arsenic. 

RICKETS 

Synonjmi. — Rachitis. 

Definition. — A  nutritional  disease  occurring  in  early  childhood 
and  characterized  by  changes  in  structure  of  the  bones,  with  conse- 
quent deformity,  muscular  weakness,  and  nervous  disturbances. 

Causes. — The  affection  usually  develops  in  the  early  months  of 
the  second  year,  although  in  rare  instances  it  may  be  congenital. 
Among  the  important  etiological  factors  may  be  mentioned  negro 
race,  foul  air,  insufficient  or  improper  food,  lack  of  sunlight,  dampness, 
poverty,  and  city  life.     Syphilis  may  be  a  cause  in  some  cases. 

The  latest  theory  is  that  rickets  is  a  "deficiency  disease,"  due  to 
a  lack  of  vitamines  in  the  child's  diet.  The  following  facts. have  been 
adduced  in  support  of  this  theory:  (i)  Rickets  is  less  frequent  and 
milder  in  breast-fed  children;  healthy  breast  milk  always  contains 
vitamines.  (2)  Breast  feeding  has  a  favorable  effect  on  rickety 
children.  (3)  The  nourishment  of  nursing  women  is  often  totally 
inadequate,  and  this  may  lead  to  deficiency  of  vitamines  in  their 
milk.  (4)  During  the  winter  months  the  food  supply  of  cows  is  often 
inferior,  this  leading  to  an  inferior  quality  of  milk.  (5)  The  harmful 
effect  produced  on  the  vitamines  of  milk  by  prolonged  boiling.  (6) 
The  harmful  results  of  feeding  children  with  starchy  foods,  which 
are  poor  in  vitamines.  (7)  The  beneficial  effect  of  cod-liver  oil, 
which  contains  vitamines,  and  also  apparently  a  substance  which 
aids  the  metabolism  of  lime  salts  in  rickety  children. 

Pathological  Anatomy. — The  structural  changes  are  most  marked 
in  the  bones  of  the  skull,  the  long  bones,  and  the  ribs.  The  head 
assumes  a  box-shape,  due  to  enlargement  of  the  parietal  and  frontal 
eminences  and  flattening  of  the  occiput  and  top  of  the  head.  The 
fontanels  often  remain  open  until  the  second  or  third  year.  In  the 
long  bones,  the  cartilages  between  the  epiphysis  and  shaft  become 
swollen  and  spongy  in  structure.  The  periosteum  is  thickened  and 
by  its  proliferation  spongy  tissue  is  also  formed.  The  affected  parts 
show  a  marked  deficiency  in  lime  salts.  The  bones  are  consequently 
soft  and  bend  easily,  giving  rise  to  deformities,  such  as  bow-legs, 
knock-knees,  pigeon-breast,  curvature  of  the  spine,  etc.     Green- 


176  DIABETES   MELLITUS 

stick  fractures  are  not  uncommon  results.  The  chondral  ends  of  the 
ribs  become  enlarged  and  nodular,  giving  the  breast  a  beaded  appear- 
ance (rachitic  rosary).  Chemical  examination  of  the  diseased 
bones  shows  an  increase  in  the  percentage  of  organic  matter  with  a 
marked  diminution  in  the  proportion  of  inorganic  or  mineral  constitu- 
ents. The  liver,  spleen,  and  sometimes  the  mesenteric  glands  are 
enlarged. 

Symptoms. — In  addition  to  the  various  changes  in  shape  in  the 
head,  chest,  and  long  bones,  there  may  also  be  present  restlessness 
and  feverishness  at  night,  with  profuse  perspiration  about  the  head, 
diffuse  tenderness,  nausea,  vomiting,  abdominal  distention,  shght 
diarrhea,  nervousness,  convulsions,  etc.  Dentition  is  delayed  and 
when  the  teeth  do  appear  they  are  badly  formed.  Muscular  weakness 
is  marked  and  prevents  the  child  from  walking  or  even  sitting  up 
(pseudo-paralysis). 
i  Complications. — The  profound  weakness  predisposes  to  all  the 
various  affections  of  childhood.  The  most  common  complications 
are  bronchial  catarrh,  bronchopneumonia,  atelectasis,  chronic  hydro- 
cephalus, diarrhea,  laryngismus  stridulus,  and  convulsions. 

Prognosis. — The  disease  is  not  fatal  in  itself,  but  may  become 
serious  in  the  presence  of  complications.  Deformities  are  common 
sequels,  and  in  the  case  of  the  female  pelvis  may  be  of  grave  import- 
ance in  subsequent  labors. 

Treatment. — The  first  indications  are  to  place  the  child  in  hygienic 
surroundings  and  to  provide  proper  food.  If  the  child  is  nursing 
and  the  mother's  milk  is  poor,  cow's  milk  should  be  substituted  and 
properly  modified  to  suit  the  individual  requirements.  Older  children 
should  be  given  beef-juice,  eggs,  and  beef  peptonoids,  in  addition 
to  milk.  Starches  and  sugars  should  be  avoided.  Orange  and  lemon 
juice  are  beneficial  in  many  cases.  Thin  gruels  may  be  used.  Cod- 
liver  oil,  syrup  of  iodide  of  iron,  hypophosphite  of  calcium,  lacto- 
phosphate  of  calcium,  Ume-water,  and  phosphorus,  are  the  drugs 
usually  employed  in  this  condition. 

DIABETES  MELLITUS 

Synon3rms. — Glycosuria;  melituria. 

Definition. — A  chronic  disorder  of  metabolism  characterized  by 
the  constant  presence  of  grape-sugar  in  the  urine,  an  excessive  urinary 
discharge,  and  the  progressive  loss  of  flesh  and  strength. 


DIABETES    MELLITUS  1 77 

Causes. — The  specific  cause  of  this  condition,  and  its  exact  nature, 
are  both  unknown.  The  affection  is  most  commonly  observed  in 
males,  most  often  in  Hebrews  between  the  ages  of  twenty-five  and 
fifty  years.  It  is  rare  in  negroes.  Among  the  most  important 
etiological  factors  may  be  mentioned  inherited  tendency,  disorders  of 
the  nervous,  hepatic,  and  renal  systems,  excessive  use  of  farinaceous 
foods  and  malt  liquors,  sedentary  habits,  mental  anxiety,  and  sexual 
excesses. 

Pathology. — The  disease  is  believed  to  be  due  primarily  to  some 
disturbance  of  the  pancreas,  the  adrenals,  pituitary,  thyroid,  or  the 
nervous  system.  Experimental  puncture  of  the  floor  of  the  fourth 
ventricle  has  produced  it,  as  has  also  disease  and  extirpation  of  the 
pancreas.  In  a  large  proportion  of  cases  it  is  possible  to  demonstrate 
changes  in  the  pancreas  (particularly  in  the  islands  of  Langerhans), 
but  more  frequently  hyperemia  and  hypertrophy,  sometimes  degen- 
eration, of  the  liver  and  kidneys  may  be  observed.  The  pathogenesis 
is  extremely  obscure.     There  are  no  constant  lesions. 

Symptoms. — Clinically,  cases  differ  greatly  in  their  course  and  se- 
verity; one  class  presenting  slight  symptoms  and  a  chronic  course; 
another  class  having  marked  local  and  constitutional  symptoms  and 
running  an  acute  course.  The  symptoms  of  a  typical  case  may  be 
arranged  under  the  following  heads : 

Urinary  Symptoms. — Micturition  is  frequent  and  accompanied 
by  pain  in  the  region  of  the  kidneys.  The  urine  is  greatly  increased 
in  quantity  (4,  8,  12,  20,  or  even  30  pints  in  twenty-four  hours). 
It  is  pale,  clear,  and  watery,  having  a  sweetish  taste  and  odor.  The 
specific  gravity  ranges  from  1025  to  1050.  It  ferments  rapidly  if 
kept  in  a  warm  place.  Sugar  is  present  in  amounts,  varying  from  an 
ounce  to  2  pounds  in  twenty-four  hours.  The  urea  and  uric  acid  are 
increased.  Albumin  may  be  present.  Acetone,  diacetic  acid  and 
beta-oxybutyric  acid  are  frequently  present  in  the  urine  of  diabetics. 
The  increased  passage  of  a  large  quantity  of  saccharine  urine  causes 
a  constant  itching,  burning  and  uneasy  sensation  at  the  prepuce, 
along  the  urethra,  and  at  the  neck  of  the  bladder;  in  females,  itching 
and  eczema  of  the  vulva  are  common;  in  children,  incontinence  of 
urine  is  frequent. 

Digestive  Symptoms. — Thirst  is  almost  constant,  and  the  mouth 
is  dry  and  parched.  The  breath  may  have  a  sweetish  odor  and  the 
tongue  is  irritable,  beefy  red,  and  often  cracked.  The  appetite  is 
variable,  at  times  excessive,  at  others,  absent.     Vomiting  occasion- 


178  DIABETES  MELLITUS 

ally  occurs.     Dyspeptic  symptoms  are  common.     Constipation,  with 
pale  and  dry  stools,  is  the  rule,  but  diarrhea  may  occur. 

General  Symptoms. — The  patient  complains  of  feeling  very  weak 
and  languid,  and  of  soreness  and  pains  in  the  limbs.  Emaciation 
soon  becomes  marked.  The  skin  is  harsh,  dry,  and  often  intensely 
itchy.  The  countenance  assumes  a  distressed  and  worn  expression. 
Various  nervous  phenomena  make  their  appearance.  Mental 
changes  are  often  noticed;  depression  of  spirits;  decline  in  firmness 
of  character  and  moral  tone;  and  irritabiHty  are  present.  Neuralgia 
and  headache  are  comnion.  Sexual  incHnation  and  power  are  greatly 
diminished.  Visual  defects  are  not  infrequent.  The  temperature 
is  usually  below  normal.  The  heart's  action  is  weak,  with  a  frequent 
low-tension  pulse.     The  blood  and  various  secretions  contain  sugar. 

Complications. — The  principal  cutaneous  complications  are  boils, 
carbuncles,  pruritus,  eczema,  and  gangrene,  especially  of  the  feet  and 
legs.  The  pulmonary  compHcations  of  greatest  frequency  are  tuber- 
culosis, lobar  pneumonia,  and  gangrene.  The  most  common  eye 
complications  are  cataract,  retinitis,  optic  atrophy,  palsies,  and  toxic 
amblyopia.  The  nervous  complications  include  peripheral  neuritis, 
ringing  in  the  ears,  deafness,  and  diabetic  coma  or  acetonemia,  a 
condition  characterized  by  unconsciousness,  dyspnea,  pain  in  the 
head,  delirium,  rapid  and  feeble  pulse,  sweetish  odor  of  the  breath, 
and  the  presence  of  acetone  in  the  urine.  Nephritis  may  also  occur 
as  a  complication. 

Course. — In  most  instances  the  course  is  chronic,  lasting  for  years, 
the  symptoms  beginning  insidiously  and  becoming  progressively 
worse,  with,  at  times,  decided  remissions.  Occasionally  the  disease 
runs  an  acute  course,  death  occurring  within  four  or  five  weeks. 

Diagnosis. — Diabetes  mellitus  only  exists  when  grape-sugar  is 
permanently  present  in  the  urine.  "It  is  not  the  quantity,  but  the 
persistence  of  sugar  which  constitutes  diabetes."  With  grape-sugar 
in  the  urine,  associated  with  more  or  less  increase  in  the  urinary  flow, 
it  should  be  mistaken  for  no  other  affection. 

It  may  be  distinguished  from  Bright' s  disease  by  the  absence  of 
dropsy  and  of  tube-casts  in  the  urine,  and  the  constant  presence  of 
sugar  in  the  urine;  but  the  amount  of  albumin  in  the  urine  is  never 
so  great  or  constant  in  diabetes  mellitus  as  in  Bright's  disease. 

From  diabetes  insipidus  it  may  be  separated  by  the  presence  of 
sugar  in  the  blood  and  urine  and  by  the  larger  quantity  of  urine 
voided  in  diabetes  insipidus. 


DIABETES   MELLITUS  1 79 

Simple  glycosuria  differs  from  diabetic  glycosuria  in  that  the  amount 
of  sugar  in  the  urine  is  not  constant — at  one  time  being  present,  at 
another  absent — the  amount  of  urine  voided  is  never  in  excess  of 
health ;  simple  glycosuria  is  a  disease  of  the  aged ;  diabetic  glycosuria 
usually  appears  under  fifty  years.  Simple  glycosuria  often  results 
from  the  inhalation  of  chloroform,  the  excessive  use  of  chloral,  and  as 
one  of  the  results  of  injuries  to  the  head.  It  may  occur  from  excite- 
ment and  in  the  insane. 

Prognosis. — The  majority  of  cases  ultimately  prove  fatal  from 
gradual  exhaustion  or  from  profound  blood-poisoning,  ending  in 
diabetic  coma  or,  rarely,  uremia.  The  compUcations  are  often  the 
direct  cause  of  death.  Amelioration  of  the  symptoms  may  occur  and 
the  progress  of  the  malady  may  be  greatly  retarded  with  treatment. 
Complete  recovery  seldom,  if  ever,  occurs.  The  younger  the  patient 
the  more  rapid  is  the  course  of  the  disease.  Surgical  operations 
should  not  be  undertaken  in  diabetic  patients  on  account  of  the 
tendency  to  gangrene. 

Treatment. — The  treatment  of  diabetes  may  be  conveniently 
considered  under  three  headings:  dietetic,  hygienic,  and  medicinal. 

Dietetic  Treatment. — The  diet  should  be  so  regulated  as  to  exclude 
or  at  least  to  reduce  to  a  minimum  the  quantity  of  starches  and 
sugars.  The  patient  should  be  allowed  to  partake  of  meats  of  every 
kind,  soups  made  with  meat  and  without  flour,  game,  poultry, 
fish,  oysters,  lobsters,  crabs,  eggs,  butter,  cheese,  oils,  fats,  cream, 
buttermilk,  milk,  spinach,  celery,  lettuce,  cabbage,  tomatoes,  aspara- 
gus tops,  water-cress,  string-beans,  onions,  cucumbers,  pickles, 
olives,  unsweetened  jellies,  almonds,  walnuts,  butternuts,  filberts, 
apples,  lemons,  strawberries,  tea  and  coffee  without  sugar,  claret. 
Burgundy,  and  Rhine  wines,  carbonated  waters,  and  bread  made 
from  gluten,  bran,  or  almond  flour. 

The  substances  which  should  be  especially  denied  the  patient  are 
ordinary  bread  or  flour,  sugar,  honey,  potatoes,  parsnips,  peas,  barley, 
beans,  rice,  tapioca,  arrowroot,  cracked  wheat,  oatmeal,  turnips, 
beets,  corn,  carrots,  prunes,  grapes,  figs,  bananas,  pears,  peaches, 
watermelons,  canteloupes,  chestnuts,  chocolate,  biscuits;  pastry, 
syrups,  preserves,  sweet  wines,  and  malt  liquors. 

When  sweetening  of  the  food  is  absolutely  necessary,  saccharin 
or  glycerin  may  be  used  for  that  purpose. 

The  latest  method  is  the  "Starvation  treatment"  of  Allen;  but 
its  adoption  demands  a  thorough  understanding  of  food  composition 


l8p  DIABETES   MELLITUS 

and  values.  The  essential  part  of  this  treatment  is  complete  rest  of 
the  alimentary  tract  so  long  as  even  a  trace  of  sugar  is  found  in  the 
urine.  The  patient  is,  first  of  all,  starved  until  his  urine  is  free  from 
sugar  and  for  a  further  period  of  twenty-four  hours.  During  this 
period  water,  tea  and  coffee  may  be  taken.  The  next  step  is  the 
arrangement  of  a-  scheme  for  diet,  in  which  the  intake  of  proteins,  of 
fats,  and  of  carbohydrates,  and  the  hulk  of  the  food  have  each  to  be 
determined.  It  is  impossible  to  lay  down  hard  and  fast  rules;  each 
case  must  be  considered  separately,  and  the  treatment  made  as 
individual  as  possible.  The  following  outline  of  this  method  of  treat- 
ment has  been  prepared  by  Dr.  Joslin  and  is  issued  by  him  to  his 
patients : 

Fasting. — Fast  until  sugar-free.  Drink  water  freely  and  tea, 
coffee  and  clear  meat  broth  as  desired.  In  very  severe,  long-standing 
and  complicated  cases,  without  otherwise  changing  habits  or  diet, 
omit  fat,  after  two  days  omit  protein  and  halve  carbohydrate  daily 
to  ID  gm.,  then  fast. 

Alcohol. — If  acidosis  (diacetic  acid)  is  present,  take  0.5  c.c.  alcohol 
per  kilogram  body  weight  daily  until  acidosis  disappears.  Alcohol 
is  best  given  in  small  doses  every  three  hours. 

Carbohydrate  Tolerance. — When  the  .twenty-four  hour  urine  is 
sugar-free,  add  150  gm.  of  5  per  cent,  vegetables,  and  continue  to 
add  5  gm.  carbohydrates  daily  up  to  20,  and  then  5  gm.  every  other 
day,  passing  successively  upward  through  the  5,  10,  and  15  per  cent, 
vegetables,  5  and  10  per  cent,  fruits,  potato  and  oatmeal  to  bread, 
unless  sugar  appears  or  the  tolerance  reaches  3  gm.  carbohydrate 
per  kilogram  body  weight. 

Protein  Tolerance. — When  the  urine  has  been  sugar-free  for  two 
days,  add  20  gm.  protein  (3  eggs)  and  thereafter  15  gm.  protein  daily 
in  the  form  of  meat  until  the  patient  is  receiving  i  gm.  protein  per 
kilogram  body  weight,  or  if  the  carbohydrate  tolerance  is  zero,  only 
%  gm.  per  kilogram  body  weight. 

Fat  Tolerance. — While  testing  the  protein  tolerance,  a  small 
quantity  of  fat  is  included  in  the  eggs  and  meat  given.  Add  no  more 
fat  until  the  protein  reaches  i  gm.  per  kilogram  (unless  the  protein 
tolerance  is  below  this  figure)  but  then  add  25  gm.  daily  until  the 
patient  ceases  to  lose  weight  or  receives  not  over  40  calories  per  kilo- 
gram body  weight. 

Reappearance  of  Sugar. — The  return  of  sugar  demands  fasting 
for  twenty-four  hours  or  until  sugar-free.     The  diet  is  then  increased 


DIABETES    MELLITUS 


l8l 


twice  as  rapidly  as  before,  but  the  carbohydrate  should  not  exceed 
half  the  former  tolerance  until  the  urine  has  been  sugar-free  for  two 
weeks,  and  it  should  not  then  be  increased  more  than  5  gm.  per  week. 
Weekly  Fast  Days. — Whenever  the  tolerance  is  less  than  20  gm. 
carbohydrate,  fasting  should  be  practised  one  day  in  seven;  when 
the  tolerance  is  between  20  and  50  gm.  carbohydrate,  upon  the  weekly 
fast  day  5  per  cent,  vegetables  and  one-half  the  usual  quantity  of 
protein  and  fat  are  allowed;  when  the  tolerance  is  between. 50  and  100 
gm.  carbohydrate,  the  10  and  15  per  cent,  vegetables  are  added  as 
well.  If  the  tolerance  is  more  than  100  gm.  carbohydrate,  upon 
weekly  fast  days  the  carbohydrate  should  be  halved. 

Poods    Arranged    Approximately    According    to    Per    Cent,    of 

Carbohydrates 


5  per  cent.* 

10  per  cent.* 

15  per  cent. 

20  per  cent. 

Lettuce 

Tomatoes 

Pumpkin 

Green  Peas 

Potatoes 

Cucumbers 

Brussels 

Turnip 

Artichokes 

Shell  Beans 

Spinach 

Sprouts 

Kohl-Rabi 

Parsnips 

Baked  Beans 

Asparagus 

Water  Cress 

Squash 

Canned 

Green  Corn 

M 

Rhubarb 

Sea  Kale 

Beets 

Lima  Beans 

Boiled  Rice     • 

Endive 

Okra 

Carrots 

Boiled 

ce 

.  Marrow 

Cauliflower 

Onions 

Macaroni 

Sorrel 

Egg  Plant 

Mushrooms 

bfl 

Sauerkraut 

Cabbage 

. 

> 

Beet  Greens 
Dandelion 

Greens 
Swiss  Chard 
Celery 

Radishes 
Leeks 

String  Beans 
Broccali 

Ripe  Olives  contain  (20  per 

Lemons 

Apples 

Plums 

cent,  fat) 

Oranges 

Pears 

Bananas 

Grape  Fruit 

Cranberries 

Apricots 

Prunes 

Strawberries 

Blueberries 

S 

Blackberries 

Cherries 

Gooseberries 
Peaches 
Pineapple 
Watermelon 

Currants 

Raspberries 

Huckleberries 

Butternuts 
Pignolias 


Brazil  Nuts 
Black  Walnuts 
Hickory 
Pecans 
Filberts 


Almonds 
Walnuts 

(English) 
Beechnuts 
Pistachios 
Pine  Nuts 


Peanuts 


40   per  cent. 

Chestnuts 


m  4) 


Unsweetened  and  Unspiced 

Pickle 
Clams  Oysters 

Scallops  Liver 

Fish  Roe 


l82 


DIABETES   MELLITUS 


Poods  Arranged  Approximately  According  to  Per  Cent,  of 
Carbohydrates. — ( Continued) 


30  gm.  (i  oz.)  contain 
approximately 


Carbohy- 
drates.grams 


Protein, 
grams 


Fat, 
grams 


Calories 


Oatmeal,  dry  weight 

Cream,  40  per  cent 

Cream,  20  per  cent 

Milk 

Brazil  Nuts 

Oysters,  six 

Meat  (uncooked,  lean) 

Meat  (cooked,  lean) 

Bacon 

Egg  (one) 

Vegetables  5  and  10  per  cent,  group 

Potato 

Bread 

Butter 

Pish,  cod,  haddock  (cooked) 

Broth 

Small  Orange  or  half  Grape  Fruit . 


20 

I 
I 

I . 
2 

4 
o 
o 
o 
o 
I  or  2 
6 
18 
o 

0 

0 

10 


s 

I 

I 

I- 

S 

6 

6 

8 

5 

6 

0.5 

I 

3 

O 

6 

0.7 

0 


2 

12 

6 

I 

20 

I 

3 

S 

IS 

6 

o 

o 

o 

25 
O 

o 
o 


no 

120 
60 
20 

210 
50 
SO 

75 
155 

75 
or  10 

25 

90 
240 

20 
3 

40 


I  gm.  protein,  4  calories. 

I  gm.  carbohydrate,       4  calories. 
I  gm.  fat,  9  calories. 

I  gm.  alcohol,  _  7  calories. 

6.25  gm.  protein  contain  i  gm. 
nitrogen 


I  kilogram  =  2.2  pounds. 

30  grams  (gm.)  or  cubic  centimeters 

(c.c.)  =  I  ounce. 

A  patient  at  rest  requires  25  calories 
per  kilogram  body  weight;  approxi- 
mately I  calorie  per  kilogram  per  hour. 


*  Reckon  available  carbohydrates  in  vegetables  of  5  percent,  group  as  3  percent., 
of  10  per  cent,  group  as  6  per  cent. 

Cards  containing  these  diet  lists,  for  the  use  of  physicians  and  patients,  can  be  obtained 
from  Thomas  Groom  and  Co.,  105  State  Street,  Boston,  Mass. 


Strict  Diet. — Meats,  fish,  broths,  gelatin,  eggs,  butter,  olive  oil, 
coffee,  tea  and  cracked  cocoa. 

Hygienic  Treatment. — Fresh  air,  daily  bathing,  and  regular  exercise 
are  essential  to  the  treatment.  Perfect  ventilation  of  the  apartment 
in  which  the  patient  works  and  sleeps  is  highly  important.  The 
use  of  various  mineral  waters  is  very  beneficial.  The  exercise  should 
be  taken  daily  and  regulated  according  to  the  patient's  strength,  being 
careful  to  avoid  overexertion.  Flannel  underclothing  should  be 
constantly  worn. 

Medicinal  Treatment. — A  great  number  of  drugs  are  recommended 
for  this  condition,  most  of  which  are  useless.  The  most  valuable 
drug  is  opium  or  one  of  its  derivatives.  Codeine,  gr.  ss  to  iij  (0.03  2 
to  0.2  gm.),  three  times  daily,  gradually  increasing  the  dose,  is  the 
alkaloid  most  commonly  employed.  Morphine  hydrochloride,  gr. 
j  (0.065  g^-)  daily,  or  powdered  opium,  gr.  iij  to  v  (0.2  to  0.3  gm.) 
daily,  may  be  used  instead.  The  constipation  which  these  prepara- 
tions are  prone  to  produce  should  be  combated  by  the  use  of  the  natu- 
ral aperient  waters,  such  as  Hunyadi,  Carlsbad, Vichy,  etc.     Arsenic, 


DIABETES  INSrproUS  1 83 

in  the  form  of  Fowler's  solution,  is  especially  valuable  in  this  disease. 
Ergot  and  ammonium  carbonate  are  also  employed  at  times  with 
benefit.  Uranium  nitrate,  gr.  iij  (0.2  gm.)  three  times  daily,  and 
sodium  salicylate,  gr.  xv  (i  gm.)  three  times  daily,  will  often  lessen 
the  quantity  of  urinary  secretion  and  reduce  the  amount  of  sugar. 
The  bromides  are  efficient  in  controlling  the  nervous  symptoms; 
potassium  or  sodium  bromide  3j  (4  g^^-)  in  twenty-four  hours,  or 
the  solution  of  the  bromide  of  arsenic,  TUiij  to  v  (0.2  to  0.3  c.c.) 
three  times  daily,  may  be  employed.  The  alkalies,  and  especially 
the  alkaline  carbonates  and  alkaline  mineral  waters,  are  of  especial 
value.  The  coal-tar  products,  antipyrine,  acetanilide  and  phenac- 
etin  in  doses  of  gr.  x  to  xv  (0.6  to  i  gm.)  three  times  daily,  combined 
with  an  equal  quantity  of  sodium  bicarbonate  will  be  found  very  suffi- 
cient in  some  cases  of  mild  type.  Powdered  jambul  seeds,  gr.  v  to  x 
(0.3  to  0.6  gm.)  three  times  daily,  and  methylene  blue,  gr.  viij  (0.52 
gm.)  daily,  have  been  used  with  success.  Among  other  drugs  used 
in  this  condition  may  be  mentioned  pepsin,  iodine,  potassium  iodide, 
lactic  acid,  glycerin,  quinine,  tincture  of  cannabis  indica,  cod-liver 
oil,  and  adrenalin.  The  galvanic  current  is  sometimes  of  value. 
The  emaciation  calls  for  the  use  of  tonics  in  addition  to  the  remedies 
employed  to  combat  the  disease.  The  sleeplessness  and  unrest 
require  morphine,  bromides,  chloral,  or  hyoscine  hydrobromide. 
The  excessive  thirst  may  be  greatly  relieved  by  the  use  of  acidulated 
water  or  alkaline  waters  which  do  not  contain  purgative  salts. 

Diabetic  coma  requires  inhalations  of  oxygen,  subcutaneous  injec- 
tions of  sodium  bicarbonate,  and  hypodermoclysis  and  enteroclysis. 
The  alkaline  treatment  is  regarded  as  a  preventive  measure  in  this 
complication. 

DIABETES  INSIPIDUS 

Synonym. — Polyuria. 

Definition. — An  affection  characterized  by  the  excessive  secretion 
of  a  very  large  quantity  of  pale,  watery  urine,  free  from  albumin  and 
sugar. 

Causes. — The  affection  may  be  inherited  or  diabetes  mellitus  may 
have  existed  in  the  parent.  It  is  most  often  observed  in  children 
and  young  adults.  Men  are  more  liable  than  women.  Injuries, 
tumors,  and  diseases  of  the  nervous  system,  hysteria,  exposure  to 
cold,  consumption  of  excessive  quantities  of  cold  water,  fatigue, 
prolonged  debility,  malaria,  syphilis,  and  intense  emotional  excitement 
may  help  to  produce  the  condition.     The  probable  immediate  cause 


184  DIABETES   INSIPIDUS 

of  the  excessive  secretion  of  urine  consists  in  dilatation  of  the  renal 
vessels,  the  result  of  paralysis  of  their  muscular  coat,  caused  by- 
derangement  of  innervation,  since  the  condition  can  be  induced 
experimentally  by  irritating  a  certain  area  in  the  fourth  ventricle, 
or  by  section  of  portions  of  the  sympathetic  nerve. 

Symptoms. — The  affection  is  characterized  by  great  thirst, 
with  an  increased  flow  of  pale,  watery,  slightly  acid  urine,  the  amount 
varying  from  one  to  five  gallons  or  six  gallons  in  the  twenty-four 
hours.  The  specific  gravity  ranges  from  i.ooi  to  1.007.  Sugar 
and  albumin  are  absent.  Urea  and  the  other  solids  are  increased. 
The  appetite  is  voracious,  the  bowels  are  obstinately  constipated, 
and  the  skin  is  dry  and  harsh.  The  large  flow  of  urine  is  usually 
preceded  by  various  nervous  phenomena,  as  nervousness,  irritability, 
inability  to  concentrate  the  mind,  vivid  imagination,  a  failure  of 
memory,  and  headache.  Unless  the  affection  is  soon  arrested,  great 
loss  of  flesh  and  strength  result. 

Diagnosis. — It  differs  from  diabetes  mellitus  by  the  absence  of 
grape-sugar  in  the  urine. 

From  paroxysmal  diuresis  by  the  presence  of  the  increased  urine 
permanently. 

From  interstitial  nephritis,  by  the  greater  amount  of  urinary  dis- 
charge and  the  absence  of  albumin,  edema,  and  casts,  and  the  cardiac 
and  vessel  changes. 

Prognosis. — Rather  unfavorable  as  to  a  radical  cure,  unless  caused 
by  syphilis.  Death  rarely  is  due  to  the  diabetes  insipidus,  but  to 
some  intercurrent  malady  which  the  patient  has  been  unable  to 
withstand,  on  account  of  the  weakness  produced  by  the  diabetes. 
Spontaneous  cure  occasionally  occurs. 

Treatment. — Restriction  of  the  fluids  has  no  effect  on  the  disease. 
Ergot,  pilocarpine,  opium,  gallic  acid,  potassium  bromide,  sodium 
salicylate,  and  valerian  have  been  used  with  varying  degrees  of  success. 
In  cases  of  syphilitic  origin,  mercury  and  potassium  iodide  should 
be  employed.  Constipation  should  be  avoided  by  the  administration 
of  compound  cathartic  pills.  Tonics,  such  as  iron,  quinine,  arsenic, 
strychnine,  etc.,  should  also  be  given  to  maintain  the  general  health. 
The  following  formula  is  productive  of  great  benefit  in  this  disease: 

I^.      Strychninse  sulphatis gr.  Ms  0.0015  gm. 

Acid,  hydrochlor.  dil TTlx  o .  6         c.c. 

Aquas  lauro-cerasi f  51]  8.0        c.c. 

M.  S.. — To  be  taken  three  times  daily  in  water. 


ALCOHOLISM  1 85 

A  vegetable  diet  has  been  recommended.  Galvanism,  applying 
one  pole  to  the  neck  below  the  occiput,  the  other  to  the  hypochondriac 
region,  is  also  of  value.  Warm  clothing,  warm  baths,  friction,  fresh 
air,  exercise,  etc.,  are  useful  adjuncts  to  the  treatment. 


THE  INTOXICATIONS  AND  SUNSTROKE 

ALCOHOLISM 

Varieties. — Acute  alcoholism;  chronic  alcoholism. 

S5mon5rms. — Acute  variety,  temulentia;  mania-a-potu. 

Chronic  variety,  delirium  tremens;  dipsomania,  or  oinomania. 

It  would  hardly  be  correct  to  consider  these  terms  interchangeable ; 
they  are  rather  names  applied  to  various  conditions  due  to  acute  or 
chronic  alcoholic  poisoning. 

Definition. — Alcoholism  is  the  term  used  to  designate  the  physical 
and  mental  phenomena  induced  by  the  use  of  alcohol.  Alcohol, 
under  certain  conditions,  is  a  poison;  but  it  becomes  a  much  more 
dangerous  one  when  associated  with  the  various  toxic  products 
which  are  added  to  flavor  it. 

Temulentia  refers,  to  drunkenness,  or  alcoholic  intoxication; 
mania-a-potu  is  an  acute  mental  derangement,  occurring  in  alco- 
holics of  strong  neurotic  tendencies;  delirium  tremens  is  an  attack 
of  delirium  associated  with  tremors  in  persons  with  the  numerous 
changes  resulting  from  chronic  alcoholism.  Delirium  tremens 
frequently  results  in  alcoholics  having  one  of  the  forms  of  nephritis, 
preventing  the  elimination  of  some  poison  developed  from  the 
ingested  alcohol.  Dipsomania,  or  oinomania,  is  an  alcoholic  insanity 
in  which  an  individual  at  longer  or  shorter  intervals  has  paroxysms 
of  alcoholic  desires,  between  which  he  neither  wishes  nor  craves 
alcohol. 

Causes. — The  predisposing  causes  are  influences  arising  from 
unfavorable  moral,  social,  and  personal  conditions,  and  heredity. 

The  exciting  cause  is  immoderate  use  of  alcoholic  beverages, 
of  which  there  are  three  groups:  (i)  spirits,  or  distilled  liquors;  (2) 
wines,  or  fermented  liquors,  and  (3)  malt  liquors. 

Pathological  Anatomy. — Acute  Alcoholism. — The  brain  is  the  seat 
of  an  active  hyperemia ;  the  mucous  membrane  of  the  stomach  and 
duodenum  is  markedly  injected  and  covered  with  a  ropy  mucus 
slightly  tinged  with  blood,  and  the  gastric  juice  is  altered  in  quality 


1 86  '  ALCOHOLISM 

and    quantity.     The    kidneys    are    also    the    seat    of    an    active 
hyperemia. 

Chronic  Alcoholism. — In  this  condition  there  are  no  organs  or 
tissues  which  do  not  present  morbid  changes.  The  gastro-intescinal 
mucous  membrane  presents  the  changes  of  chronic  catarrhal  inflam- 
mation ;  the  liver,  the  first  organ  to  receive  the  poison  after  the  stomach 
shows  congestion,  cirrhosis,  or  fatty  degeneration;  the  kidneys  show 
chronic  congestion  and  often  the  changes  incident  to  chronic  inter- 
stitial nephritis.  The  muscular  structure  of  the  heart  may  undergo 
fatty  degeneration,  and  the  vessels  the  changes  of  senility.  The 
brain-stnicture  presents  the  changes  of  sclerosis  in  various  stages, 
and  there  may  be  chronic  meningitis,  and  pachymeningitis  with 
hematoma.  The  nerves  are  altered,  atrophied,  and  hardened,  and 
the  neuroglia,  vessels,  and  ganglion  cells  of  the  spinal  cord  show 
similar  changes. 

Symptoms. — Acute  alcoholism,  resulting  from  the  use  of  a  large 
quantity  of  alcoholic  fluid,  occurs  with  the  symptoms  varying  from 
mild  intoxication  to  drunkenness,  passing  to  acute  delirium  and 
acute  coma.  The  condition  begins  with  a  period  of  exhilaration, 
passing  to  semi-delirium  and  ending  in  an  acute  coma,  when  the 
breathing  is  stertorous,  the  face  bloated  and  congested,  the  lips 
swollen  and  purplish,  the  pupils  contracted  or  dilated,  the  pulse  feeble 
and  slow,  the  skin  cold  and  clamrdy,  the  temperature  depressed,  and 
frequently  control  of  sphincters  lost.  An  individual  so  affected  is 
said  to  be  "dead  drunk." 

Cases  of  ordinary  drunkenness  do  not  often  pass  beyond  the  stage 
of  exhilaration,  ending  in  a  mild  coma  or  sleep. 

Mania-a-potu,  or  acute  alcoholic  delirium,  is  the  direct  result  of 
alcoholic  excess  in  those  engaged  in  a  sudden  debauch,  or  who  have 
drunk  alcoholic  beverages  very  "hard"  for  a  comparatively  short 
period.  The  individuals  grow  more  and  more  excitable,  lose  all 
desire  for  food,  are  unable  to  sleep,  become  the  prey  of  horrible  hal- 
lucinations— "the  horrors" — flnally  terminating  in  mania  which 
resembles  delirium  tremens  in  all  save  the  tremor,  which  is  absent. 

Delirium  Tremens. — In  the  majority  of  instances,  delirium  results 
in  a  chronic  drinker,  from  a  prolonged  debauch,  with  abstinence 
from  proper  food.  It  begins  by  an  increased  tremor,  insomnia,  irri- 
table, excited  manner,  followed  by  the  characteristic  hallucinations 
and  illusions,  during  which  snakes  and  other  forms  of  repulsive  reptiles 
are  seen,  causing  the  most  intense  horror  and  abject  fear;  it  is  a  busy 


ALCOHOLISM  1 87 

delirium,  the  patient  being  unable  to  remain  quiet.  There  also  occur 
illusions  of  smell  and  hearing.  This  marked  excitement  is  followed 
by  great  depression,  the  skin  is  cold  and  clammy,  the  pulse  feeble,  the 
muscular  system  weak,  the  mind  in  a  condition  of  coma-vigil,  and, 
if  continued,  a  febrile  condition,  typhoid  in  character,  with  stupor 
or  coma,  develops.  Uremic  symptoms  frequently  complicate  the 
condition,  the  temperature  suddenly  bounding  to  103°,  104°  or  io5°F., 
with  albumin  and  casts  in  the  scanty  urine. 

The  ordinary  duration  of  an  attack  of  delirium  tremens  is  about 
two  weeks  in  those  who  recover,  although  death  may  occur  at  any  time 
from  cardiac  failure,  uremia,  or  alcoholic  pneumonia.  Indeed,  pa- 
tients sometimes  die  suddenly  after  the  beginning  of  apparent  im- 
provement. Convalescence  dates  from  the  beginning  of  refreshing 
sleep,  the  patient  awakening  with  a  clear  mind  and  desire  for  food. 
Should  the  delirium  subside,  but  the  patient  continue  to  mutter  and 
pick  at  the  bed-clothing,  the  tongue  become  dry  and  cracked,  and  the 
regurgitation  of  dark  brownish  and  bilious  matter  occur,  the  condi- 
tion is  critical  and  an  early  fatal  termination  may  be  expected. 

Dipsomania,  or  oinomania,  is  the  inherited  or  acquired  mental 
condition  which  craves  the  drinking  of  intoxicating  liquors.  This 
is  a  true  mental  disease.  It  manifests  itself  in  periodic  attacks  of 
excessive  indulgence  in  alcoholic  drinking,  or  this  symptom  of  the 
sad  disease  may  be  replaced  by  other  irresistible  desires  of  an  im- 
pulsive kind,  such  as  lead  to  the  commissio*n  and  repetition  of  various 
crimes,  the  gratification  of  other  depraved  appetites,  robbery,  or  even 
homicide.     ImbeciUty  and  dementia  frequently  result. 

The  paroxysms  at  first  occur  at  ■  long  intervals,  but  gradually 
the  intervals  become  shorter  and  shorter  until  the  individual  entirely 
surrenders  himself  to  alcoholic  and  other  excesses. 

Chronic  Alcoholism. — The  condition  to  which  this  term  has  been 
given  is  truly  a  disease.  It  is  the  result  of  the  continued  use  of  alco- 
holic beverages  until  one  or  more  of  the  morbid  organic  changes  have 
occurred.  These  persons  are  markedly  dyspeptic,  with  coated 
tongue,  fetid  breath,  and  early  morning  vomiting,  straining,  or  retch- 
ing, attended  with  much  distress.  There  is  a  gradually  developing 
muscular  tremor,  progressing  to  the  ataxic  gait.  Insomnia,  or  rest- 
less sleep  is  frequent.  The  face  may  either  become  pallid,  flabby, 
and  bloated,  with  an  imbecile  expression,  or  swollen,  rough,  and  dusky, 
with  great  bladders  under  the  eyes,  and  yellow,  injected  conjunctivas. 
There  are  headache,   vertigo,   and  attacks   of  hallucinations;  the 


1 88  •  ALCOHOLISM 

memory  grows  weaker,  the  judgment  less  accurate,  the  moral  sense 
blunted,  and  the  will-power  weak  and  erratic.  These  and  many  other 
symptoms  add  to  the  distress  of  the  individual,  which  he  attempts 
to  overcome  by  the  use  of  more  and  more  of  the  poison. 

Diagnosis. — Profound  drunkenness,  or  alcoholic  coma,  may  be, 
and  often  is,  confounded  with  apoplectic  and  uremic  coma.  Von 
Wedekind  suggests  the  following  method  for  diagnosing  drunkenness : 
"By  simply  pressing  on  the  supraorbital  notches  with  a  steadily 
increasing  force  one  may,  with  certainty  of  success,  bring  an  uncon- 
scious alcoholic  to  his  senses,  and  thus  differentiate  between  alcoholic 
and  other  comas." 

The  symptoms  of  chronic  alcoholism  often  bear  a  close  resemblance 
to  the  following  maladies:  General  paralysis,  disseminated  sclerosis, 
paralysis  agitans,  locomotor  ataxia,  cerebral  and  spinal  softening, 
epilepsy,  dementia  chronica,  and  nervous  dyspepsia. 

In  individuals  whose  habits  are  secret,  the  question  of  diagnosis 
is  attended  with  considerable  difficulty.  Anstie  lays  much  stress 
upon  the  importance  of  the  following  four  points,  diagnostic  of 
chronic  alcohoHsm:  insomnia,  morning  vomiting,  muscular  tremor, 
and  causeless  mental  restlessness. 

Prognosis. — In  acute  alcohoHsm  the  prognosis  is  good  if  the  patient 
is  manageable. 

In  chronic  alcoholism  the  organic  changes,  the  direct  result  of  the 
alcoholic  habit,  tend  to  shorten  life  by  the  production  of  fatty  heart, 
Bright's  disease,  insanity,  epilepsy,  melanchoHa,  and  organic  brain 
diseases.  The  danger  in  delirium  tremens  is  heart  failure  or  deepen- 
ing coma.  The  association  of  chronic  nephritis  with  delirium  tremens, 
perhaps  its  cause,  must  always  be  taken  into  account  in  determining 
a  prognosis.  Acute  lobar  pneumonia  is  a  very  fatal  complication 
in  all  forms  of  alcohoHsm. 

Treatment. — In  deciding  upon  a  plan  of  medication  for  any  of  the 
varieties  of  alcoholism  the  condition  of  the  kidneys,  heart,  and  vessels 
must  be  considered.  The  treatment  of  a  case  of  ordinary,  drunken- 
ness requires  little  consideration,  as  the  rapid  elimination  of  the,  alco- 
hol soon  occurs  if  its  ingestion  be  stopped.  The  contents  of  the  stom- 
ach should  be  immediately  removed  by  the  stomach -tube  or  by  the 
hypodermic  injection  of  apomorphine,  gr.  J^o  (0.0066  gm.).  If, the 
attack  is  not  sufficiently  severe  to  warrant  these  procedures,  fractional 
doses  of  calomel  every  half  hour  followed  by  a  saline  will  be  of  great 
benefit.     The  solution  of  ammonium  acetate  in  large,  frequently 


ALCOHOLISM  1 89 

repeated  doses  greatly  assists  in  the  elimination  of  the  poison.  When 
the  excitement  is  extreme,  chloral,  gr.  xv  to  xxx  (i  to  2  gm.),  should 
be  given.  Morphine  is  of  great  value  in  many  of  these  cases,  but  the 
presence  of  any  kidney  complication  is  a  contra-indication  for  its  use. 
Aromatic  spirit  of  ammonia  is  also  of  value  in  this  condition. 

For  the  collapse  following  a  lethal  dose  of  alcohol,  the  stomach 
should  be  immediately  emptied  by  emetics  or  the  stomach- tube, 
and  the  organ  washed  out  with  warm  water  or  coffee,  the  patient 
placed  in  a  recumbent  position,  and  surrounded  with  artificial  warmth, 
and  hot  frictions  applied  to  the  lower  extremities.  Resort  should 
be  had  to  artificial  respiration  or  the  use  of  faradism  to  the  thorax, 
inhalations  of  ammonia,  and  hypodermic  injections  of  strychnine 
sulphate,  nitroglycerin,  digitalis,  strophanthus,  or  atropine  sulphate. 
Tapping  of  the  precordial  region  with  a  hot  spoon  (Corrigan's 
hammer)  may  serve  also  to  stimulate  the  flagging  heart. 

For  mania-a-potu,  the  immediate  and  complete  withholding  of 
alcoholic  beverages  is  essential  for  its  successful  treatment.  The 
patient  should  be  quieted  as  soon  as  possible.  The  restlessness, 
insomnia,  delirium,  and  visual  and  auditory  hallucinations  are  usually 
controlled  with  chloral,  and  on  account  of  the  gastric  torpor  and 
catarrh,  interfering  with  the  prompt  absorption  of  medicaments,  it 
is  best  given  by  the  bowel: 

I^.     Chloral gr.  xx  to  xxx     i .  3  to  2  gm. 

Infus.  digitalis f §3  30.0  c.c. 

M.  S. — Repeat  in  two  hours,  in  milk. 

If  for  any  reason  an  enema  is  impracticable,  chloral  or  trional, 
gr.  xxx  (2  gm.),  should  be  given  by  the  mouth,  or  hypodermic  injec- 
tions of  morphine  sulphate,  gr.  3^  to  3^  (0.016  to  0.022  gm.), 
combined  with  atropine  sulphate,  gr.  3^00  (^0.00065  gm.),  or  hyoscine 
hydrobromide,  gr.  3^00  (0.00065  g^-)?  may  be  employed.  Chloral- 
ose,  gr.  V  to  x  (0.33  to  0.66  gm.),  and  paraldehyde,  f  3  ss  to  j  (2t0  4  c.c), 
may  also  be  used.  Physical  restraint  may  be  required.  An  attack 
of  acute  alcoholism,  or  mania-a-potu,  may  often  be  aborted  with 
trional,  gr.  xxx  (2  gm.),  repeated  in  two  hours,  or  chloralamide,  gr. 
xxx  to  xl  (2  to  6  gm.),  repeated.  Excellent  and  prompt  results  follow 
the  use  of  a  hot-air  bath,  until  profuse  sweating  occurs. 

If  one  or  two  medicinal  doses  of  the  selected  sedative  drug  do  not 
produce  quiet  and  sleep,  be  most  cautious  in  repeating,  remembering 
that  the  patient  is  suffering  from  the  depressing  effects  of  a  cardiac 


IQO  •  ALCOHOLISM 

and  nerve  poison,  which  is  best  combated  by  eliminating  action  on 
skin,  bowels,  and  kidneys,  and  the  administration  of  food.  If  the 
attack  be  associated  with  symptoms  of  cardiac  depression,  we  may 
try  brisk  friction,  hot  alcohol  and  water  sponging,  artificial  warmth, 
stimulating  enemata,  and  the  hypodermic  administration  of  strych- 
nine sulphate,  gr.  3^o  to  ^o  (0.003  to  0.002  gm.),  repeated,  or 
citrated  caffeine,  gr.  iij  (0.2  gm.),  or  digitalis. 

The  general  nutrition  should  be  given  attention,  as  in  most  cases 
it  will  be  found  that  the  patient  has  had  very  Httle  food  for  several 
days.  If  the  stomach  will  tolerate  food — and  usually  it  will — milk 
diluted  with  liquor  calcis  or  Seltzer  water,  or  hot  beef -tea,  strongly 
seasoned  with  capsicum,  should  be  administered  every  hour  or  two 
in  small  amounts. 

The  appetite  is  stimulated  by  the  use  of  the  following : 

I^.     Tinct.  nucis  vomicae fSiv  150.0. 

Tinct.  capsioi f  3iv  15  c.o. 

Tinot.  oinchonae  comp f  §ij  60  0.0. 

M.   S. — One  teaspoonful,   diluted,  every  two  or  three  hours. 

This  stomachic  stimulant  may  be  alternated  with  aromatic  spirit 
of  ammonia,  f5j  (4  c.c.)  given  in  hot  milk,  with  advantage  to  the 
heart  and  nervous  system.  The  bowels  should  be  moved  at  once  by 
the  administration  of  an  enema: 

I^.     Magnesii  sulphat Bij  60.  gm 

Glyoerini f Sj  '  30.  c.c 

Aquae  bul f  Siv  120.  c.c 

M.  S. — Use  as  directed. 

The  kidneys  should  be  stimulated  by  full  doses  of  spirit  of  nitrous 
ether  if  the  patient  is  able  to  swallow,  and  if  not,  by  the  hypodermic 
injection  of  citrated  caffeine. 

In  delirium  tremens,  the  patient  should  be  isolated  and  placed 
under  the  care  of  a  skillful,  sensible  nurse.  The  alcohol  may  be  entirely 
withdrawn  or  its  quantity  greatly  reduced.  Tyson  advises  complete 
withdrawal  of  the  poison,  combating  any  resulting  adynamia  with 
ammonia,  digitalis,  and  strychnine.  The  stomach  should  be  washed 
out  daily  and  an  easily  digested  diet  should  be  supplied.  A  free 
action  of  the  skin,  kidneys,  and  bowels  should  be  obtained  as  soon  as 
possible  to  effect  elimination  of  the  poisonous  products  retained  in  the 
system.     The  excitability  of  the  nervous  system  ahould  be  controlled 


ALCOHOLISM  IQI 

by  nerve  sedatives.  For  this  purpose,  hypodermic  injections  of 
morphine  sulphate,  gr.  y^  (0.016  gm.),  combined  with  atropine 
sulphate,  gr.  3^00  (0.00065  gm.),  or  hyoscine  hydrobromide,  gr. 
Hoo  (0.00065  gm.),  or  chloral  or  trional  by  the  mouth  or  rectum 
are  especially  applicable.  When  the  stomach  is  not  too  irritable  the 
following  will  be  found  of  value: 

I^.     Chloral 3iv  I5  gm. 

Tr.  capsici f  3ij  8  c.c. 

Aquas  menth.  pip.,  .q.  s.  ad  f  Svj  ad     180  c.c. 

M.  S. — Tablespoonful  every  two  hours  until  sleep,  alternated 
with  a  cup  of  hot  beef-tea,  to  which  has  been  added  a  bolus  of 
capsicum,  gr.  xx  (1.3  gm.). 

Care  should  be  taken  not  to  produce  coma  by  these  remedies. 
Not  more  than  two  doses  in  six  hours  should  be  allowed  but  instead 
push  the  administration  of  hot  liquid  diet  and  atropine  sulphate, 
gr.  ^^4  (o.ooi  gm.),  with  strychnine  nitrate,  gr.  y^,^  (0.002  gm.), 
hypodermically,  as  experience  has  proven  that  these  drugs  given  three 
times  daily  in  reducing  doses,  are  the  physiological  antidotes  to  the 
alcoholic  poison. 

When  the  depression  and  cardiac  weakness  are  great,  strychnine 
sulphate,  citrated  caffeine,  spirit  of  chloroform,  ammonium  carbonate, 
strophanthus,  and  digitalis  are  of  value.  Atony  of  the  stomach 
requires  lavage  and  the  administration  of  the  previously  mentioned 
capsicum  mixture.  When  for  any  reason  the  nerve  sedatives  already 
advised  are  contra-indicated,  paraldehyde,  chloralamide,  or  the 
bromides  may  be  employed.  Strict  attention  must  be  given,  at  all 
times,  to  the  condition  of  the  skin,  bowels,'  and  kidneys.  If  the  heart 
is  not  much  depressed,  the  cautious  use  of  the  hot-air  bath  or  the 
hypodermic  injection  of  pilocarpine  hydrochloride,  gr.  y^  (0.02  gm.), 
repeated  at  the  onset  of  the  mania  will  be  found  of  great  value. 

Chronic  Alcoholism. — The  combination  of  symptoms  termed  chronic 
alcoholisn  are  the  direct  result  of  the  continuous  action  of  a  poison, 
and  no  success  of  even  a  temporary  kind  can  be  expected  unless  the 
poison  be  withdrawn.  The  rapidity  with  which  this  can  be  accom- 
plished is  a  question  of  skill,  judgment,  and  experience  of  the  physician 
to  determine;  the  chief  obstacle  to  its  success  will  be  found  to  be 
moral  rather  than  physical.  Next  to  the  disuse  of  alcohol  is  the 
question  of  diet.  Progress  will  be  made  as  the  appetite  and  digestion 
improve,  and  great  attention  should  be  given  to  these.     The  general 


192  CHRONIC   OPIUM   POISONING 

health  will  also  be  benefited  by  fresh  air,  exercise,  mental  occupation, 
and  cold  or  tepid  sponging  and  an  occasional  hot  bath  at  bedtime. 
For  the  combination  of  symptoms  of  spirit-craving,  morning  vomiting, 
muscular  tremor,  mental  restlessness,  and  insomnia,  no  drug  is 
comparable  with  strychnine  nitrate,  either  hypodermically  twice 
daily,  or,  what  is  preferable,  by  the  stomach  to  secure  its  local  action 
on  the  mucous  membrane.  If  the  insomnia  be  persistent  in  spite  of 
the  foregoing  treatment,  the  temporary  use  may  be  made  of  such 
remedies  as  chloral,  morphine  sulphate,  paraldehyde,  or  trional. 
In  many  cases  it  is  desirable,  for  its  mental  effect,  if  no  other,  to  ad- 
minister what  the  patient  terms  a  substitute  for  his  alcoholic  bever- 
ages.    The  following  is  a  good  combination  for  that  purpose: 

I^.     Tincturae  nucis  vomicae.  ..  .  fgss  150.0. 

Tinoturae  capsioi f  Bss  15  o.c. 

Fluidext.  lupulini f  5iij  90  c.c. 

Inf.  gent,  comp f  §ij  60  c.c. 

M.  S. — Dessertspoonful  three  or  four  times  daily,  well  diluted. 

For  the  anemia,  loss  of  strength,  and  mental  debility,  benefit  may 
follow  the  use  of  syrup  of  hypophosphites  with  strychnine. 

The  Lambert  method  of  treatment  has  proved  very  successful; 
see  under  Chronic  Opium  Poisoning,  page  193. 

Dipsomania. — The  management  of  these  cases  is  much  the  same 
as  has  already  been  mentioned  for  chronic  alcoholism,  although  the 
strychnine  sulphate  treatment  should  be  given  the  preference. 
Hypodermics  of  apomorphine  sulphate  in  small  doses,  yio  gr., 
every  four  hours,  or  just  enough  to  keep  the  patient  somnolent,  have 
proved  beneficial. 

CHRONIC  OPIUM  POISONING 

Sjmonjmis. — Morphinomania;  morphinism. 

Symptoms. — There  is  a  craving  for  the  drug  which  is  well-nigh 
irresistible;  the  patient  shows  loss  of  strength  and  weight,  a  sallow 
complexion,  anorexia,  disturbed  digestion,  insomnia,  mental  depres- 
sion, extreme  irritability,  anemia,  muscular  and  mental  weakness, 
and  a  tendency  to  lie.  Pruritus  is  common  and,  of  course,  the  pupils 
are  contracted,  and  the  secretion  of  saliva  and  sweat  is  decreased. 

Treatment. — Since  the  patient  will  obtain  his  "poison"  if  it  is  at 
all  possible  for  him  to  do  so,  isolation  in  an  institution  is  practically 
essential.     Withdrawal  of  the  drug,  somewhat  rapidly  but  not    too 


CHRONIC    OPIUM   POISONING  1 93 

abruptly,  is  recommended .  Tonics  and  nutritious  foods  are  necessary, 
and  rest  in  bed  is  advisable.  Sulphonal  or  paraldehyde  may  be  used 
for  the  insomnia;  and  other  symptoms  may  be  treated  as  they  arise. 
The  Lambert  method  of  treatment  has  been  successfully  employed, 
and  it  is  herewith  appended. 

Lambert's  Treatment  for  Narcotic  Addiction. — "A  patient  addicted 
to  morphine  is  given  five  compound  cathartic  pills  and  5  gr.  of  blue  mass, 
and,  six  hours  later,  if  these  have  not  acted,  they  are  followed  by  a  saline; 
after  three  or  four  abundant  movements  of  the  bowels  from  these 
cathartics,  the  patient  is  given,  in  three  divided  doses  at  half-hour 
intervals,  two-thirds  of  the  total  daily  twenty-four-hour  dose  of  morphine 
or  opium  to  which  he  has  been  accustomed.  Observe  carefully  after 
the  second  dose  has  been  given,  as  the  amount  then  equals  four-ninths 
or  nearly  one-half  the  total  twenty-four-hour  dose.  Some  few  patients 
cannot  comfortably  take  more  than  this  amount.  At  the  same  time 
with  the  morphine  6  drops  of  the  belladonna  mixture  are  given  in  capsules, 
[The  belladonna  mixture  consists  of  2  parts  of  15  per  cent,  tincture  of 
belladonna,  and  i  part  each  of  the  fluidextracts  of  hyoscyamus  and 
xanthoxylum.  It  is  a  most  important  part  of  the  treatment.]  This 
belladonna  mixture  in  doses  of  6  drops  (and  by  drops  are  not  meant 
minims,  but  drops  dropped  from  an  ordinary  medicine  dropper,  which  is 
about  half  a  minim  dose)  is  given  every  hour  for  six  hours.  At  the  end 
of  six  hours  the  dosage  is  increased  2  drops.  The  belladonna  mixture 
is  continued  every  hour  of  the  day  and  every  hour  of  the  night  con- 
tinuously throughout  the  treatment,  increasing  2  drops  every  six  hours 
until  16  drops  are  taken,  when  it  is  continued  at  this  dosage;  it  is  dimin- 
ished or  discontinued  at  any  time  if  the  patient  shows  belladonna  symp- 
toms such  as  dilated  pupils,  dry  throat  or  redness  of  the  skin,  or  the 
peculiar  and  incisive  and  insistent  voice,  and  insistence  on  one  or  two 
ideas.  It  is  begun  again  at  reduced  dosage  after  the  above  symptoms 
have  subsided. 

"At  the  tenth  hour  after  the  initial  dose  of  morphine  is  given,  the 
patient  is  again  given  five  compound  cathartic  pills,  and  5  gr.  of  blue 
mass.  These  should  act  in  six  or  eight  hours  after  they  have  been 
taken.  If  they  do  not  act  at  this  time  some  vigorous  saline  is  given, 
and  when  they  have  acted  thoroughly  the  second  dose  of  morphine  is 
given,  which  is  usually  about  the  eighteenth  hour.  This  should  be  one- 
half  the  original  dose;  i.e.,  one-third  of  the  original  twenty-four-hour 
daily  dose.  The  belladonna  mixture  is  still  continued,  and  ten  hours 
after  the  second  dose  of  morphine  has  been  given,  that  is  about  the 
twenty-eighth  hour,  five  compound  cathartic  pills  are  again  given  and 
5  gr.  of  blue  mass,  these  again  if  necessary  followed  by  a  saline  seven  or 
eight  hours  later.  At  times  when  the  C.  C.  pills  are  not' acting  well, 
13 


194  CHRONIC   OPIUM  POISONING 

or  too  slowly,  five  or  six  "B.  B."  pills  are  given  from  two  to  three  hours 
after  the  C.  C.  pills.  These  "B.  B."  pills  are  the  piliilse  catharticae 
vegetabiles  of  the  pharmacopeia  with  }{o  gr.  of  oleoresin  of  capsicum, 
3^  gr.  of  ginger,  and  3^5  minim  of  croton  oil  added  to  each  pill.  After 
these  have  thoroughly  acted  at  about  the  thirty-sixth  hour,  the  third 
dose  of  morphine  is  given,  which  is  one-sixth  of  the  original  dose.  This 
is  usually  the  last  dose  of  morphine  that  is  necessary.  Again,  ten  hours 
after  this  third  dose  of  morphine,  i.e.,  the  forty-sixth  hour,  the  five  C. 
C.  pills  and  5  gr.  of  blue  mass  are  again  given,  followed  in  seven  or  eight 
hours  afterward  by  a  saline,  and  one  expects  at  this  time  to  see  the  bilious 
green  stool  appear.  When  this  appears,  after  the  bowels  have  moved 
thoroughly,  ten  or  twelve  hours  after  the  third  dose  of  morphine,  about 
the  fifty-sixth  hour,  2  ounces  of  castor  oil  are  given  to  clear  out  thoroughly 
the  intestinal  tract.  During  this  last  period  when  the  bowels  are  moving 
from  the  C.  C.  pills  and  before  the  oil  is  given,  the  patients  have  their 
most  uncomfortable  time.  Their  nervousness  and  discomfort  can  be 
controlled  usually  by  codeine,  which  can  be  given  hypodermicaUy  in  5 
gr.  doses  and  repeated  if  necessary,  or  some  form  of  the  valerianates 
may  help  them.  About  the  thirtieth  hour  these  patients  should  be 
stimulated  with  strychnine  or  digitalis,  or  both.  After  they  are  off  their 
drug,  the  tonics  which  do  them  the  most  good  are  those  which  contain 
some  form  of  phosphorus  and  arsenic;  and  here  a  warning  must  be  given 
as  to  the  danger  of  these  patients  overeating,  and  thus  bringing  back 
aU  their  withdrawal  symptoms  due  to  the  disturbance  of  digestion. 
They  have  been  in  the  habit  of  referring  all  uncomfortable  feelings  to 
those  of  the  withdrawal  symptoms  of  morphine,  and  digestive  disturbances 
feign  these  withdrawal  symptoms.  Sometimes  about  the  thirty-sixth 
hour  the  stools  become  clay-colored.  Some  form  of  prepared  ox-gall  is 
most  effective  to  stimtdate  further  biliary  secretion  given  in  smaU  doses 
every  hour  for  five  or  six  doses. 

"In  treating  an  alcoholic,  the  belladonna  mixture  and  the  five  C.  C. 
pills  and  5  gr.  of  blue  mass  are  given  simultaneously  at  the  first  dose. 
The  belladonna  mixture  is  continued  every  hour  of  the  day  and  every 
hour  of  the  night  the  same  as  with  the  morphine  patients,  and  twelve 
hours  after  the  initial  dose  patients  are  again  given  from  three  to  five 
C.  C.  pills,  and  at  the  twenty-fourth  hour  after  the  initial  dose,  they  are 
again  given  the  cathartics  followed  by  salines  if  necessary,  and  again 
at  the  thirty-sixth  hour.  After  these  cathartics  the  bilious  stools  will 
appear,  and  by  the  forty-fourth  or  forty-fifth  hour  the  castor  oil  is  given. 
Sometimes  it  is  necessary  to  carry  on  the  treatment  over  another  period, 
and  the  C.  C.  pills  and  blue  mass  are  again  given  at  the  forty-eighth 
hour,  which  would  bring  the  end  of  the  treatment  about  the  sixtieth 
hour."     (From  Gould  and  Pyle's  Cyclopedia  of  Medicine  and  Surgery.) 


HEAT    STROKE  1 95 

PELLAGRA 

Definition. — An  endemic  or  epidemic  disease,  characterized  by  nerv- 
ous, gastric,  and  cutaneous  symptoms,  and  whose  cause  is  unsettled. 

Etiology. — Middle  age,  unsanitary  surroundings,  unwholesome  food, 
and  the  spring  months  of  the  year  seem  to  be  predisposing  factors. 
The  laboring  class  is  chiefly  attacked.  The  actual  cause  is  said  to 
be  maize;  and  "the  morbific  action  of  maize  has  been  variously  attrib- 
uted to — 

(a)  Deficiency  in  its  nutritive  principles. 

(b)  Specific  toxic  substance  contained  normally  in  the  grain. 

(c)  Poisons  elaborated  after  it  has  been  ingested. 

(d)  Toxic  substances  elaborated  during  decomposition  of  the 
grain. 

(e)  Fungi  or  bacteria  found  on  maize."     (Manson). 

Sambon  regards  the  disease  as  being  caused  by  an  animal  parasite 
conveyed  by  the  Stomoxys  calcitrans;  others  have  attributed  it  to  a 
bacteriumj. 

Symptoms. — ^Languor,  debility,  and  disinclination  to  work  are 
prodromata.  Pallor,  headache,  pain  in  back  and  joints,  giddiness, 
coated  tongue,  epigastric  pain  or  tenderness,  constipation,  or  bloody 
diarrhea,  are  then  noted.  This  is  followed  or  accompanied  by  an  ery- 
thema on  face,  neck,  chest,  back  of  hands,  and  feet,  and  forearms 
and  legs.  This  lasts  two  weeks,  and  leaves  the  skin  rough.  Nervous 
symptoms  are  present,  such  as  exaggerated  reflexes,  tongue  tremor, 
insomnia,  melancholia. 

Improvement  may  follow,  but  exacerbations  occur.  The  prognosis 
is  not  very  good. 

Treatment  consists  in  the  internal  administration  of  arsenic 
(sodium  cacodylate,  atoxyl  or  soamin)  and  liberal  and  nutritious 
diet.  Fresh  fruit,  milk,  eggs,  fresh  peas  or  beans  have  proved 
beneficial.  No  rational  line  of  treatment  can  be  outlined  so  long 
as  the  cause  of  the  disease  is  unknown.  The  practitioner  should 
treat  symptomatically  the  dermatitis,  diarrhea,  and  depression. 

HEAT  STROKE 

Sjmonjrms. — Insolation;  sunstroke;  thermic  fever;  coup-de-soleil; 
heat  exhaustion. 

Definition. — A  depression  of  the  vital  powers,  the  result  of  exposure 
to  excessive  heat.  The  condition  manifests  itself  as  acute  meningitis 
(rare),  heat  exhaustion  (common),  and  as  true  sunstroke. 


196  HEAT    STROKE 

Causes. — Exposure  to  the  influence  of  excessive  heat,  either  to  the  " 
direct  rays  of  the  sun  or  artificial  heat  in  confined  quarters,  or  diffused 
atmospheric  heat  without  proper  ventilation. 

Among  the  predisposing  causes  which  act  by  lessening  the  power 
of  the  system  to  resist  the  heat  are  great  bodily  fatigue,  overcrowding, 
and  intemperance. 

Pathological  Anatomy. — The  action  of  the  heat  upon  the  system 
is  so  sudden,  and  the  malady  so  rapid  in  its  course,  that  structural 
changes  seldom  develop.  The  left  ventricle  is  firmly  contracted 
(Wood).  The  right  heart  and  vessels  are  engorged  with  dark  fluid 
blood.  All  the  tissues  and  organs  of  the  body  are  in  a  state  of  great 
venous  congestion.  The  blood  is  dark,  thin,  and  either  feebly  alka- 
line or  decidedly  acid,  and  its  coagulability  is  destroyed.  The  post- 
mortem rigidity  is  early  and  marked. 

Sjnnptoms. — These   depend  upon  the   variety   of  the   affection. 

Acute  meningitis,  the  result  of  exposure  to  heat,  has  symptoms 
similar  to  those  of  cases  due  to  other  causes. 

Heat  exhaustion  develops  with  a  rapid  feeling  of  weakness  and 
prostration,  the  surface  is  cool,  the  face  pale,  the  voice  weak,  the  pulse 
rapid  and  feeble,  the  respiration  increased,  the  vision  grows  dim  and 
indistinct,  noises  develop  in  the  ears,  the  individual,  overcome,  be- 
comes partially  or  completely  unconscious.  In  some  cases  the  attack 
of  prostration  is  sudden,  the  person  falHng  unconscious,  with  perhaps 
convulsions  or  tremors  and  shrunken  features. 

Sunstroke  develops  suddenly,  with  or  without  prodromes,  and  is 
manifested  by  insensibility  with  or  without  delirium,  convulsions, 
or  paralysis,  flushed  and  hot  body-surface,  injected  conjunctivae, 
rapid  and  shallow  or  labored  and  stertorous  breathing,  quick  pulse 
either  bounding  or  weak,  and  an  axillary  temperature  ranging  from 
105°  to  108°  to  I  io°F.,  with  suppression  of  all  glandular  action.  When 
death  occurs  it  results  from  asphyxia  or  from  slow  failure  of  respira- 
tion and  the  circulation. 

Diagnosis. — It  is  of  great  importance,  therapeutically,  to  dis- 
tinguish at  once  between  attacks  of  sunstroke  and  heat  exhaustion. 
This  may  be  readily  done  by  the  aid  of  a  thermometer.  Cases  of 
simstroke  are  to  be  differentiated  from  cerebral  hemorrhage  and 
alcoholic  insensibility  by  the  history,  season,  occupation,  and  by  the 
temperature. 

Prognosis. — Attacks  of  heat  exhaustion,  if  properly  and  promptly 
treated,  are  favorable.     The  prognosis  of  sunstroke^  or  heat-fever, 


HEAT   STROKE  1 97 

is  unfavorable  in  the  majority  of  cases,  death  resulting  in  from  half 
an  hour  to  several  hours.  Unfavorable  indications  are  increased 
temperature,  cardiac  failure,  convulsions,  and  absent  reflexes,  followed 
by  complete  muscular  relaxation. 

Favorable  indications  are  decline  in  surface  heat  and  axillary 
or  rectal  temperature,  stronger  pulse,  increased  depth  of  respirations, 
restored  reflexes,  and  return  of  consciousness. 

Sequels. — In  any  form  of  this  affection  one  or  more  of  the  fol- 
lowing conditions  may  result:  headache,  vertigo,  insomnia,  epilepsy, 
mental  enfeeblement,  and  monoplegia,  paraplegia,  or  hemi- 
plegia. 

Treatment. — In  heat  exhaustion,  the  patient  should  be  placed  in  the 
recumbent  posture  with  the  head  low  and  stimulants  administered. 
Hot  applications  are  of  great  value.  If  the  patient  is  able  to  swallow, 
brandy,  §ss  to  j  (15  to  30  c.c),  with  deodorized  tincture  of  opium, 
TTlxv  to  XXX  (i  to  2  c.c),  should  be  given  at  once  and  repeated  if  the 
occasion  requires  it.  Aromatic  spirit  of  ammonia,  f  §  j  (4  c.c),  in  hot 
water  or  milk  every  half  hour  is  a  useful  adjunct.  If  the  patient  is 
unable  to  swallow,  these  remedies  may  be  given  by  enema,  or  whiskey, 
strychnine  sulphate,  and  tincture  of  digitalis  may  be  used  hypodermic- 
ally.  As  convalescence  begins,  tonic  doses  of  quinine  hydrochloride 
and  strychnine  sulphate  should  be  prescribed. 

In  sunstroke,  the  indications  for  treatment  are  directly  opposite. 
The  patient  is  in  imminent  danger  from  the  extraordinary  tempera- 
ture, and  measures  to  reduce  it  must  at  once  be  instituted.  Of  these 
none  give  such  excellent  results  as  rubbing  with  ice,  the  cold  bath  or 
cold  pack,  and  cold  effusions,  cold  enemata,  and  the  hypodermic  use 
of  quinine  sulphate  or  antipyrine.  The  tendency  to  subsequent  rise 
of  temperature  is  met  by  wrapping  the  patient  in  a  wet  sheet  and 
repeating  the  hypodermic  medication,  unless  consciousness  has  been 
regained,  when  the  remedies  may  be  given  by  the  mouth.  If  con- 
vulsions and  restlessness  occur,  morphine  sulphate,  gr.  3^^  to  ^^ 
(0.016  to  0.032  gm.),  hypodermically,  cautiously  repeated  if  necessary, 
or  chloral  or  bromides  by  the  rectum  will  be  of  value.  In  the  occur- 
rence of  depression,  strychnine  sulphate,  gr.  3='^4  (0.0025  g^i-)? 
repeated  every  half  hour  hypodermically,  together  with  other  modes 
of  stimulation,  is  indicated.  Hypodermoclysis  and  enteroclysis  may 
also  be  of  value  under  such  circumstances.  During  convalescence 
iron,  quinine  and  other  tonics  are  required. 


198  -CAISSON  DISEASE 

CAISSON  DISEASE 

Synonyms. — The  bends;  diver's  paralysis. 

Description. — The  symptoms  due  to  increased  atmospheric  pres- 
sure, sometimes  occurring  in  divers,  caisson  workers,  etc.  Para- 
plegia, hemiplegia,  anesthesia,  or  apoplectic  attacks  are  common, 
but  paralysis  of  the  legs  is  the  most  frequent  symptom,  coming  on 
only  after  return  to  the  normal  atmosphere.  The  nature  of  the  lesion 
is  obscure. 

Predisposing  Causes.- — These  are,  too  long  stay  in  the  compressed 
air,  insufficient  ventilation  of  the  compressed  air  space, — the  amount 
of  illness  varies  inversely  with  the  extent  of  the  provision  for  ventila- 
tion,— too  rapid  decompression,  fulness  of  habit,  advancing  age,  over- 
indulgence in  alcohol,  and  organic  disease.  New  hands  suffer  more 
than  the  old. 

Symptoms. — The  leading  symptoms,  as  given  by  Parkes  are:  (i) 
Unpleasant  sensations  or  severe  pains  in  the  ears,  which  may  be 
materially  aggravated  if  the  person  happens  to  be  suffering  from  a 
cold  in  the  head  or  sore  throat,  when  pain  in  the  forehead  is  often 
marked.  (2)  _  Neuralgic  pains.  (3)  A  feeling  of  giddiness,  with  a 
tendency  to  fall.  (4)  Loss  of  power  in  the  legs,  amounting  at  times  to 
paralysis.  (5)  Slight  to  severe  pains  in  the  legs,  arms,  and  shoulders. 
(6)  Epistaxis.  (7)  Itching  of  skin.  (8)  Hemoptysis.  (9)  Epigastric 
pain,  and  sometimes  nausea  and  vomiting.  (10)  Occasionally 
unconsciousness.  There  is,  of  course,  a  physiological  rise  in  the  blood 
pressure. 

Treatment. — The  affection  may  be  prevented  to  some  extent  by 
avoiding  sudden  changes  in  the  atmospheric  pressure  and  long- 
continued  work  under  high  pressure.  Slow  decompression,  and  a 
careful  selection  of  the  worker  will  do  much  to  prevent  this  dis- 
ease. No  worker  should  be  accepted  who  is  suffering  from  obesity, 
arteriosclerosis,  cardiac  weakness,  nephritis,  anemia  or  chlorosis,  or 
neurasthenia. 

DISEASES  OF  THE  DIGESTIVE  SYSTEM 

DISEASES  OF  THE  MOUTH 

Introduction. — The  angles  of  the  mouth  may  be  seats  of  radiating 
scars  due  to  old  syphilitic  cracks  or  fissures.  Herpes  or  fever  blisters 
in  the  same  situation  may  lead  to  more  or  less  confusion,  but  the 


CATARRHAL    STOMATITIS  1 99 

duration  and  absence  of  scarring  will  soon  render  the  diagnosis 
clear.  The  inside  of  the  lips,  the  buccal  mucous  membrane,  and  the 
tonsils  may  be  affected  by  the  initial  lesion  of  syphilis,  the  chancre, 
and  in  all  indurated  lesions  in  these  situations  this  disease  should  be 
carefully  considered.  Mucous  patches  or  moist  papules  are  common 
on  the  mucous  membrane  of  the  mouth  and  their  importance  arises 
from  their  contagious  nature.  Inflammation  of  the  gums,  or  gingi- 
vitis, is  a  rare  condition  which  may  arise  from  gonorrheal  infection, 
mercurial  poisoning,  scurvy,  and  other  similar  constitutional  diseases. 
A  blue  line  on  the  gums,  near  the  insertion  of  the  teeth,  is  indicative 
of  lead-poisoning.  First  dentition  is  usually  completed  at  the  end 
of  the  second  year,  and  the  permanent  teeth  begin  to  appear  in  the 
sixth  year,  any  delay  in  dentition  or  the  eruption  of  badly  formed 
teeth  is  attributed  to  nutritional  disorders,  such  as  occur  in  rickets 
and  syphilis.  Hutchinson^s  teeth  consist  in  certain  characteristic 
alterations  in  the  permanent  teeth,  and  indicate  congenital  syphilis. 
The  lateral  incisors  are  peg-shaped,  and  the  central  incisors  have  con- 
vex sides  and  notched  cutting  edges.  Carious  teeth  may  arise  from 
uncleanliness  of  the  mouth,  drugs,  and  nutritional  disturbances. 

As  a  mouth -wash  for  soft  and  spongy  gums,  the  following  is  recom- 
mended by  Whitla : 


SiB.    '^lY  1 6  CO. 


I^.     Tincturse  myrrhas 

Tincturse  kramerias 

Tincturae  cinchonse 

Tincturae  catechu 

Eau  de  Cologne,  §j.  32  c.c. 

M.  S. — A  teaspoonful  in  a  wineglassful  of  water,  to  be  used 
as  a  mouth- wash. 

CATARRHAL  STOMATITIS 

Synon3rms. — Simple  stomatitis;  erythematous  stomatitis. 

Description. — An  acute  catarrhal  inflammation  of  the  whole  or 
a  portion  of  the  mucous  membrane  of  the  mouth  and  tongue,  charac- 
terized by  pain,  redness,  sweUing,  restlessness,  slight  fever,  fetor  of 
the  breath,  and  disordered  secretion.  It  is  most  common  in  infants 
and  children.  It  results  from  the  introduction  of  irritants  into 
the  mouth,  gastrointestinal  disturbances,  delayed  dentition,  and  the 
infectious  fevers.  Chronic  stomatitis  occurs  mostly  in  adults  as  the 
result  of  alcoholic  or  tobacco  excesses,  or  of  carious  or  of  badly  ar- 
ranged artificial  teeth. 


200  APHTHOUS    STOMATITIS 

Treatment. — The  most  important  point  in  the  treatment  is  the 
removal  of  the  exciting  cause,  attention  to  the  secretions  and  diet, 
and  gently  mopping  out  the  mouth  at  frequent  intervals  with  a  soft 
wad  of  absorbent  cotton  and  cold  or  iced  water,  or  diluted  Dobell's 
solution  (see  page  60),  or  the  following: 

I^.     Sodii  boratis gr.  xc  6  gm. 

-Aquae  destillat f  §  jss  45  c.c. 

Mel.  rosse f  B  jss  45  c.c. 

M,  S. — Mouth-wash. 

In  severe  or  aggravated  cases  a  dilute  solution  of  silver  nitrate, 
gr.  ij  to  V  (0.13  to  0.32  gm.),  to  f  §j  (30  c.c),  should  be  applied. 


APHTHOUS  STOMATITIS 

Sjoionyms. — Follicular  stomatitis;  vesicular  stomatitis;  herpetic 
stomatitis;  croupous  stomatitis;  canker.  Note. — Aphthous  stomati- 
tis is  not  aphthae;  the  latter  is  synonymous  with  thrush  (see  pa.ge  201). 

Description. — An  acute  inflammation  of  the  follicles  and  mucous 
membrane  of  the  mouth  and  tongue,  characterized  by  a  fibrinous 
or  croupous  exudation ;  the  exudation  first  appearing  in  isolated  spots 
{discrete),  afterward  coalescing,  and  forming  large  and  irregular- 
sized  patches  {confluent)  which  rupture,  leaving  an  ulcer  which 
slowly  heals.  The  disease  occurs  mostly  in  childhood  and  is  due  to 
difficult  dentition,  disorders  of  digestion,  uncleanliness,  and  the 
eruptive  fevers.  The  lesions  appear  usually  as  small  white  vesicles 
which  subsequently  rupture.  Pain,  difficulty  in  swallowing,  saliva- 
tion, feverishness,  and  fetor  of  the  breath  are  present. 

Treatment. — The  exciting  cause  should  be  removed  if  possible. 
The  mouth  should  be  cleansed  after  each  feeding,  and  nursing  bottles 
and  nipples  should  be  sterilized  by  boiling.  Digestive  disturbances 
should  be  corrected  by  the  administration  of  powders  containing 
calomel,  gr.  ]/i2  (0.005  gm.),  ^^d  sodium  bicarbonate,  gr.  j  (0.065 
gm.),  every  three  hours.  Small  doses  of  quinine  sulphate  may  be 
necessary  in  protracted  cases.  Locally,  chlorate  of  potassium  or 
boric  acid  in  solution  will  be  of  benefit.  The  ulcers  may  be  touched 
with  a  weak  solution  of  silver  nitrate  (gr.  iv  to  f  §  j).  Honey  and  bo- 
rax— the  mel  horacis  of  the  British  Pharmacopoeia — is  also  efficacious. 


THRUSH  20 I 

ULCERATIVE  STOMATITIS 

Synonyms. — Pseudomembranous  stomatitis;  fetid  stomatitis; 
putrid  sore  mouth. 

Definition. — An  acute  and  severe  inflammation  of  the  mucous 
membrane  of  the  mouth  attended  with  necrosis  and  terminating  in 
ulceration. 

Causes. — It  is  probably  infectious  in  character  but  no  specific 
microorganism  is  yet  recognized  as  the  cause.  It  may  be  epidemic, 
and  is  apt  to  accompany  or  follow  improper  feeding,  infectious  diseases, 
or  metallic  poisoning.  Unhygienic  surroundings  and  local  irritation 
are  also  factors. 

Symptoms. — It  begins  with  swelling  of  the  mucous  membrane 
about  the  base  of  the  teeth  and  adherent  deposits  appear  on  the  gums, 
which  eventually  become  gray  or  black  and  separate  as  sloughs,  leav- 
ing behind  irregular  ulcers.  The  lower  jaw  is  most  often  affected, 
but  it  may  extend  to  the  lips,  cheeks,  or  tongue.  The  submaxillary 
glands  are  swollen  and  tender.  Pain  is  present;  mastication  and 
deglutition  are  difficult;  the  mouth  is  hot;  the  saliva  dribbles  away 
mixed  with  blood  and  pulpy  matter;  the  breath  is  fetid;  anorexia 
is  present ;  the  patient  is  feverish  and  restless ;  and  the  gastrointestinal 
tract  is  disordered  in  its  functions. 

Prognosis. — A  favorable  termination  may  be  expected  when  the 
affection  is  promptly  and  properly  treated  and  when  the  ulcerated 
surface  is  not  too  extensive. 

Treatment. — The  exciting  and  contributory  causes  should  be  im- 
mediately removed.  Internally  potassium  chlorate,  gr.  i  to  5  (0.065 
to  0.32  gm.),  should  be  administered  in  solution  every  three  hours 
Iron,  quinine,  strychnine,  and  alcohol  may  be  necessary  if  there  is 
much  depression.  Locally,  potassium  chlorate  solution,  bismuth, 
alum,  or  silver  nitrate  solution,  may  be  applied.  Potassium  per- 
manganate (in  the  form  of  Condy's  fluid,  one  teaspoonful  to  a  tumbler 
of  water)  is  a  useful  wash.  If  the  mouth  is  particularly  sensitive 
and  tender  a  little  opium  may  be  added  to  the  mouth-washes  that 
are  used. 

THRUSH 

Synonjmis. — Parasitic  stomatitis;  mycotic  stomatitis;  muguet; 
soor;  stomatomycosis ;  aphthae.  {Note. — This  is  7iot  aphthous  stoma- 
titis, see  page  200.) 


202  .    GANGRENOUS    STOMATITIS 

Description. — An  inflammation  of  the  mucous  membrane  of  the 
mouth,  associated  with  or  caused  by  the  growth  of  a  parasitic  plant, 
the  Oidium  albicans;  characterized  by  pain,  disorders  of  digestion 
and  _of  the  bowels.  It  is  most  common  in  bottle-fed  infants,  but 
may  be  seen  in  adults  in  the  last  stages  of  cancer  or  consumption. 
The  mucous  membrane  of  the  mouth  presents  a  dark  red  appearance 
in  isolated  patches  on  which  whitish  points  appear  and  rapidly  coa- 
lesce. These  whitish  points  are  made  up  of  epithelium,  fat,  and 
fungus,  and  resemble  curdled  milk.  The  symptoms  common  to 
the  other  forms  of  stomatitis  are  also  present. 

Prognosis. — The  termination  is  favorable  under  treatment  in  all 
cases  except  those  due  to  malignant  diseases. 

Treatment. — Absolute  cleanliness  as  regards  the  baby's  mouth, 
nursing  bottles,  nipples,  etc.,  is  necessary.  The  disordered  digestive 
tract  should  receive  attention,  largely  by  the  proper  modification  of 
the  milk.  A  saturated  solution  of  sodium  hyposulphite,  TUiij  to  x 
(0.18  to  0.6  c.c),  may  be  given  internally  and  also  applied  locally. 
Sodium  bicarbonate,  and  sodium  biborate  may  also  be  employed 
locally. 

I^.     Sodii  boratis gr.  Ix  4  gm. 

Glycerini f5ij  8  c.c. 

Aquae f5vj  24  c.c. 

M.   S. — To  be  thoroughly  applied  four  or  five  times  daily,- 
and  continued  for  a  week  after  the  disappearance  of  the  affection. 

Honey  is  to  be  avoided,  since  it  may  induce  acid  fermentation; 
hence  the  mel  boracis  referred  to  on  page  200  must  not  be  given 
in  this  condition.  In  obstinate  cases  the  patches  should  be  wiped 
and  then  touched  with  i  or  2  per  cent,  solution  of  nitrate  of  silver. 

GANGRENOUS  STOMATITIS 

Synonyms. — Cancrum    oris;    noma;    water-cancer. 

Definition. — An  acute,  rapidly  progressive  gangrenous  ulceration 
of  the  mouth,  leading  to  extensive  sloughing  and  destruction  of  the 
affected  tissues. 

Causes. — It  is  probable  that  gangrenous  stomatitis  is  due  to  some 
parasitic  microorganism,  but  its  character  is  as  yet  unknown.  It 
attacks  feeble  and  sickly  children  by  preference;  and  is  occasionally 
observed  in  adults.     It  may  occur  as  a  primary  affection,  but  is  most 


MERCURIAL    STOMATITIS  203 

often  encountered  as  a  sequel  to  measles,  scarlet  fever,  typhoid  fever, 
or  pneumonia. 

S5nnptoms. — All  the  symptoms  common  to  the  other  varieties  of 
stomatitis  are  present  to  a  marked  degree.  One  of  the  first  mani- 
festations is  the  penetrating,  gangrenous  odor.  The  cheek  is  swollen 
and  edematous,  and  the  skin  has  a  glazed,  waxy  appearance.  On 
e version  of  the  cheek  a  foul  sloughing  ulcer  is  brought  into  view, 
which  shortly  perforates  the  skin  and  discharges  externally.  Con- 
stitutional reaction  is  severe;  the  temperature  is  high  and  irregular; 
the  pulse  rapid  and  feeble;  and  prostration  is  marked.  Diarrhea 
is  common.  Death  usually  terminates  the  affection  in  a  week  to 
ten  days.  Recovery  is  very  rare.  Characteristics  of  the  disease 
are:  (i)  That  it  begins  on  the  inside  of  the  cheek;  (2)  that  it  is  almost 
always  unilateral;  (3)  that  it  perforates  the  whole  thickness  of  the 
cheek;  and  (4)  that  it  is  rapidly  fatal. 

Treatment  to  be  of  any  use  must  be  prompt  and  vigorous.  E ver- 
sion of  the  cheek  with  cauterization  of  the  ulcer  by  stick  silver 
nitrate,  fuming  nitric  acid,  or  the  Paquelin  cautery  is  the  first  indica- 
tion. The  mouth  should  then  be  kept  as  clean  as  possible  by  means 
of  peroxide  of  hydrogen,  boric  acid  solution,  or  other  mild  antiseptics. 
The  strength  of  the  patient  should  be  maintained  by  the  frequent 
administration  of  nourishing  food,  whiskey  or  brandy,  quinine,  iron, 
strychnine,  and  other  tonics. 

MERCURIAL  STOMATITIS 

Synonym. — Mercurial  ptyalism. 

Etiology  and  S3nnptoms. — The  ingestion  and  absorption  of  mercur- 
ial preparations  in  excess  of  their  physiological  dose  or  in  abnormally 
susceptible  individuals  induce  tenderness  of  the  gums,  fetor  of  the 
breath,  metallic  taste,  increase  in  saliva,  and  redness  of  the  mucous 
membrane  of  the  mouth.  In  marked  cases  salivation  is  profuse, 
the  tongue  is  swollen  and  protrudes  from  the  mouth;  and  necrosis 
of  the  teeth  and  jaw  may  occur. 

Treatment. — The  mercurial  preparations  should  be  immediately 
suspended,  and  potassium  iodide  administered  in  small  doses.  A 
saturated  solution  of  potassium  chlorate  should  be  employed  as  a 
mouth-wash.  Atropine  may  be  given  to  control  the  excessive  se- 
cretion of  saliva.     Tonics  are  often  necessary  to  combat  the  anemia. 


204  '•      LUD wig's   angina 


LUDWIG'S  ANGINA 


Synonyms. — Angina  Ludovici;  cellulitis  of  the  neck. 

Definition  and  Symptoms. — A  phlegmonous  inflammation  of  the 
floor  of  the  mouth  and  tissues  about  the  side  of  the  neck.  It  is 
probably  a  streptococcus  infection  and  is  observed  after  the  infectious 
fevers,  traumatism,  and  dental  caries.  It  may  end  in  suppuration, 
gangrene,  septicemia,  and  very  rarely  resolution.  Pain,  swelling, 
dysphagia,  dyspnea,  and  grave  constitutional  symptoms  are  present. 

Treatment. — Tonics  and  stimulants  internally  and  ice  and  leech- 
ing locally  are  indicated.  Surgical  interference  is  usually  necessary; 
in  the  meantime  antiseptic  measures  should  be  employed. 


DISEASES  OF  THE  TONGUE 

Coating  of  the  Tongue. — Normally,  the  color  of  the  anterior  two- 
thirds  of  the  tongue  is  a  pale  red,  while  the  posterior  third  is  grayish. 
On  the  anterior  portion  are  seen  the  fungiform  papillae  as  bright 
red  points,  and  on  the  posterior  portion  the  circumvallate  papillae 
arranged  in  two  rows  of  red  circles.  Fur  on  the  tongue  is  due  to 
accumulated  epithelium,  fungi,  and  food  particles.  It  is  uniform 
in  febrile  diseases,  gastrointestinal  disorders,  nasopharyngeal  affec- 
tions, and  not  uncommonly  in  health.  A  circumscribed  furring 
usually  points  to  some  local  oral  trouble.  Unilateral  furring  results 
from  some  disturbance  of  the  second  and  third  branches  of  the  fifth 
nerve.  Localized  thickenings  of  the  epithelium  of  the  tongue  give 
to  it  a  chart-like  appearance  to  which  the  term  geographical  tongue  is 
applied.  Intense  white  spots  on  the  mucous  membrane  constitute 
leukoplakia.  The  pale  tongue  is  noticed  in  anemia.  The  dry,  brown, 
and  fissured  tongue  accompanies  the  low  fevers,  such  as  typhoid 
fever  and  dysentery.  The  black  tongue  may  be  parasitic  in  nature, 
but  is  usually  observed  in  malignant  fevers.  A  bluish-black  tongue 
is  occasionally  seen  in  Addison's  disease.  The  red,  beefy  tongue  is 
most  often  encountered  in  diabetes  and  similar  wasting  diseases. 
The  strawberry  tongue  consists  of  a  more  or  less  uniform  whitish 
coating,  through  which  project  the  bright  red  fungiform  papillae;  it 
is  seen  in  scarlet  fever.  Trembling  tongtie  may  be  seen  in  paresis 
and  similar  nervous  diseases,  alcoholism,  and  asthenic  fevers. 


/ 
ULCERATION   OF   THE   TONGUE  205 

GLOSSITIS 

Definition. — An  inflammation  of  the  parenchyma  of  the  tongue; 
characterized  by  great  swelHng  of  the  organ,  with  difficult  mastica- 
tion, deglutition,  and  vocalization.  It  may  be  acute  or  chronic. 
The  affection  may  be  due  to  injury,  contact  with  boiling  liquids  or 
other  irritating  substances,  or  stings  of  insects. 

Symptoms. — The  tongue  is  swollen,  painful,  and  sometimes  pro- 
trudes from  the  mouth,  thus  interfering  with  mastication  and  degluti- 
tion. The  discomfort  is  extreme.  The  voice  is  muffled  and  there 
may  be  dyspnea.  There  is  increased  flow  of  saliva.  Fever  and  other 
constitutional  phenomena  are  present.  Suppuration  may  occur. 
Acute  glossitis  usually  terminates  in  recovery  within  a  week,  although 
death  may  occur  from  suffocation.  Chronic  glossitis  persists  indefi- 
nitely, being  manifested  largely  by  pain  aggravated  by  movements 
of  the  tongue. 

Treatment. — The  application  of  ice  to  the  tongue  and  to  the  jaw 
affords  relief  in  most  cases.  Occasionally  heat  must  be  substituted. 
Deep  scarification  is  necessary  in  aggravated  cases.  Suppuration 
indicates  prompt  incision.  Antiseptic  mouth  washes  should  be 
employed  constantly.  In  chronic  glossitis,  silver  nitrate  in  stick 
or  solution  should  be  applied  to  ulcerated  areas.  The  constitutional 
phenomena  should  be  treated  on  general  principles.  If  suffocation 
appears  imminent  tracheotomy  must  be  performed. 

SYPHILIS  OF  THE  TONGUE 

Syphilis  of  the  tongue  may  appear  as  the  chancre,  mucous  patch, 
or  gumma.  The  characteristics  of  these  lesions  are  maintained  in 
this  structure.  The  chancre  is  distinguished  largely  by  its  parch- 
ment-like induration,  and  the  age  at  which  it  appears.  The  mucous 
patch  is  usually  associated  with  other  signs  of  secondary  syphilis 
and  the  gumma  is  diagnosed  by  exclusion  and  the  therapeutic  test. 
(See  the  article  on  Syphilis,  pages  89  and  96.) 

Treatment. — Mercury  and  the  iodides,  alone  or  combined,  should 
be  administered  over  an  extended  period. 

ULCERATION  OF  THE  TONGUE 

Simple  ulceration  may  result  from  carious  teeth,  gastrointestinal 
irritation,  and  contact  with  irritants.     The  underlying  causes  should 


2o6  ,        I.EUKOPLAKIA  BUCCALIS 

be  removed  and  the  ulcerated  areas  touched  with  silver  nitrate  in 
stick  form  or  in  solution. 

Tuberculous  ulceration  is  rare  and  appears  on  the  dorsum,  near 
the  tip  of  the  tongue,  as  an  irregularly  oval  ulcer  with  undermined 
edges  and  an  uneven  base,  which  is  covered  with  coarse  pinkish-gray 
granulations.  It  is  incurable.  The  general  treatment  for  tubercu- 
losis may  be  employed,  supplemented  by  the  use  of  the  a:-ray. 

Malignant  ulceration  is  usually  due  to  epithelioma,  and  occurs 
with  greatest  frequency  in  men  past  forty  years  of  age.  The  lesion 
has  hard  and  everted  edges,  with  an  uneven,  excavated  base.  The 
adjacent  tissues  are  infiltrated  and  indurated,  and  the  neighboring 
glands  are  involved.  Neuralgic  pain  is  constant.  Removal  of  the 
organ  is  indicated.  The  affection  terminates  fatally.  Radiotherapy 
may  be  of  benefit. 

LEUKOPLAKIA  BUCCALIS 

Synonyms. — Smoker's  tongue;  smoker's  patches;  ichthyosis 
lingualis. 

Description. — It  is  of  unknown  origin,  but  is  most  common  in 
smokers;  it  consists  of  irregular,  smooth,  white  patches  on  the  tongue, 
and  sometimes  on  the  inside  of  the  cheek. 

Treatment. — It  is  very  obstinate  to  treatment.  All  irritants 
should  be  avoided.  Silver  nitrate  (lo  per  cent,  solution),  chromic 
acid  (i  per  cent,  solution),  and  corrosive  sublimate  (1:500)  have 
been  recommended  for  local  use;  but  too  active  treatment  should  be 
avoided. 

FOUL  BREATH 

The  chief  causes  of  this  condition  are:  pyorrhoea  alveolaris;  ton- 
sillitis; diphtheria;  indigestion;  diseases  of  mouth,  pharynx,  or 
stomach;  decayed  teeth,  and  neglect  of  proper  hygiene  of  mouth 
and  teeth;  diseases  of  nose,  bronchi  or  lungs;  chronic  constipation; 
mineral  poisons. 

The  treatment  consists  in  discovering  and,  if  possible,  removing  the 
cause.  The  teeth  and  gums  should  receive  the  first  attention;  the 
former  should  be  cleansed,  and  the  latter  sponged  with  a  solution  of 
myrrh  and  water.  A  mouth-wash  of  thymol  gr.  vijss  (0.50  gm.), 
borax  gr.  xv  (i.o  gm.),  and  distilled  water  i  pint  (500  gm.)  may  be 


ACUTE   CATARRHAL  PHARYNGITIS  207 

used ;  or  i  grain  of  potassium  permanganate  to  i  ounce  of  rose  water. 
The  following,  to  be  used  as  wafers,  have  also  been  recommended: 

I^.     Pulv.  carui  sem., 

Pulv.  coriandri  sem., 

Pulv.  cinnam aa   3ss  2  gm. 

Sach.  alb 3]  4  gm. 

Mucil.  gum.  acacise q.  s. 

V 

S. — Make    fifty    pills.     Dissolve    one    in    the    mouth    when 
necessary. 

I^.     Pulv.  cinnam., 
Pulv.  pimentge, 

Pulv.  cardam aa  5ss  2  gm, 

Sacchari  alb 5  J .  4  gm. 

Mucil.  gum.  acaciae q.  s. 

S. — Make    fifty    pills.     Dissolve    one    in    the    mouth    when 
necessary. 

DISEASES  OF  THE  PHARYNX  AND  TONSH^S 

ACUTE  CATARRHAL  PHARYNGITIS 

S3nion3mis. — Sore  throat;  simple  angina. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  tonsils,  uvula,  soft  palate,  and  pharynx;  character- 
ized by  rigors,  fever,  painful  deglutition,  coughing,  or  constant 
desire  to  clear  the  throat,  with  a  more  or  less  decided  nasal  intonation 
of  the  voice. 

Causes. — Exposure  to  cold  and  wet,  infective  microorganisms, 
local  irritants,  such  as  hot  liquids  and  noxious  gases,  rheumatism, 
gout,  and  the  eruptive  fevers  may  give  rise  to  acute  pharyngitis. 

S3miptoms. — The  onset  is  sudden,  usually  with  rigors  followed  by 
fever,  thirst,  headache,  anorexia,  coated  tongue,  foul  breath,  dryness 
of  the  throat,  painful  deglutition,  hoarseness,  and  a  constant  desire 
to  clear  the  throat,  due  to  the  increased  length  of  the  uvula.  Exten- 
sion to  the  Eustachian  tube  and  middle  ear  gives  rise  to  deafness  and 
earache.  The  nasal  tone  of  the  voice  is  almost  pathognomonic. 
Inspection  of  the  pharynx  reveals  an  intensely  red  and  swollen  condi- 
tion of  the  mucous  membrane.  The  tonsils  and  larynx  may  also  be 
involved.  Secretions  are  first  lessened,  but  soon  become  increased 
and  assume  a  thick,   tenacious,   opaque  character. 


2o8  -CHRONIC  PHARYNGITIS 

Prognosis. — Favorable.  The  affection  terminates  in  three  or  four 
days  by  the  discharge  of  a  quantity  of  thick,  opaque  mucus. 

Treatment. — "Twenty-four  hours'  rest  in  bed  is  by  far  the  best 
medicine  for  an  ordinary  cold"  (Tyson).  Cases  resulting  from  expo- 
sure are  benefited  by  the  application  of  bicarbonate  of  sodium  by 
insufflation.  Opium  alone  or  combined  with  ipecac  or  camphor 
will  often  abort  an  attack.  Pain  may  be  relieved  by  the  administra- 
tion of  salol,  gr.  iij  (0.2  gm.),  phenacetin,  gr.  iij  (0.2  gm.),  and  pow- 
dered camphor,  gr.  j  (0.65  gm.),  four  to  six  times  daily.  Tincture 
of  the  chloride  of  iron  in  doses  of  2  to  10  minims  may  be  given. 
Sodium  salicylate,  gr.  x  to  xv  (0.6  to  i  gm.)  every  hour,  for  six  hours, 
is  of  great  benefit.  Tincture  of  aconite  or  potassium  citrate,  may 
be  given  to  control  the  fever.  The  bowels  should  always  be  freely 
opened  early  in  the  treatment. 

Locally  the  application  of  a  4  per  cent,  solution  of  cocaine  or 
cocaine  lozenges  will  afford  considerable  relief.  Ice  pellets  in  the 
mouth  and  heat  or  cold  applied  externally  also  produce  benefit. 
Gargles  or  sprays  of  alum  (gr.  viij  to  f§j),  ammonium  chloride  (gr. 
XX  to  f^j))  or  potassium  chlorate  (gr.  x  to  f§j),  often  relieve  the 
swelling  and  congestion. 

The  severe  cases  are  nearly  always  secondary  affections,  and  their 
treatment  is  that  of  the  primary  diseases. 

CHRONIC  PHARYNGITIS 

Synonyms. — Clergyman's  sore  throat;  granular  pharyngitis; 
chronic  angina. 

Description. — Chronic  inflammation  of  the  pharynx  follows  re- 
peated acute  attacks,  prolonged  irritation,  long-continued  overuse 
and  improper  use  of  the  voice,  chronic  rhinitis,  and  digestive  dis- 
turbances. It  is  common  in  hucksters,  public  speakers,  singers, 
and  smokers.  It  is  more  common  in  adults  than  in  children;  and  the 
inhalation  of  dust  and  irritating  gases  may  also  induce  the  trouble. 
In  the  early  stage  the  mucous  membrane  is  in  a  state  of  chronic 
hyperemia;  and  is  thick,  swollen,  and  studded  with  distended  follicles 
and  enlarged  lymphatic  glandules  which  give  to  it  a  granular  appear- 
ance. In  the  later  stage  the  mucous  membrane  undergoes  atrophic 
changes,  and  is  anemic,  glossy,  and  dry.  As  a  result  of  these  changes 
the  voice  is  husky,  and  the  throat  is  dry.  Distress  follows  the  use  of 
the  voice  and  there  is  a  constant  desire  to  clear  the  throat. 


ACUTE    TONSILLITIS  209 

Treatment. — As  a  prophylactic,  in  "threatened"  sore  throat,  the 
following  has  been  recommended: 

I^.     Acidi  tannici gr.  xij  0-75  gm. 

Tincturae  iodi ITlv  o .  32  c.c. 

Acidi  carbolici gr.  xxx  2  .  o    gm. 

Glycerini §ss  16.0    c.c. 

Aquae q.  s.  ad   giij  96.0    c.c. 

M.  S. — Paint  the  throat  with  this  three  times  a  day. 

The  underlying  causes  should  be  promptly  removed.  Tonics  such 
as  iron,  quinine,  strychnine,  and  cod-liver  oil,  together  with  plenty 
of  fresh  air,  should  be  prescribed.  Locally,  Dobell's  solution  and 
similar  antiseptic  solutions  should  be  used  in  the  pharynx  and  nose. 
When  the  granules  are  present,  astringent  applications,  such  as 
zinc  sulphate  (gr.  v  to  f§  j)  and  silver  nitrate  (gr.  x  to  xx  to  f  §3),  or 
the  galvanocautery  may  be  employed.  A  spray,  consisting  of  men- 
thol (gr.  ij),  eucalyptol  (gr.  j),  and  liquid  vaseline  will  be  productive 
of  great  relief.     The  condition  may  prove  very  resistant  to  treatment. 

ULCERATION  OF  THE  PHARYNX 

Ulceration  of  the  pharynx  seldom  follows  simple  chronic  pharyn- 
gitis, but  results  from  syphilis,  tuberculosis,  diphtheria,  typhoid 
fever,  or  scarlet  fever.  This  history,  character  of  the  ulceration, 
and  reaction  to  treatment  will  aid  greatly  in  making  a  diagnosis. 
The  syphilitic  ulcer  is  either  painless,  or  but  slightly  painful,  and  is 
generally  on  the  posterior  wall  of  the  pharynx.  The  tuberculous 
ulcer  is  very  painful,  and  is  associated  with  tuberculosis  elsewhere; 
it  is  also  on  the  posterior  wall  of  the  pharynx.  The  treatment  is 
largely  that  of  the  primary  disease,  but  locally,  in  all,  mild  antiseptic 
and  stimulating  applications  should  be  made  to  the  ulcerated  areas. 

ACUTE  TONSILLITIS 

Sjnionyms. — Quinsy;  amygdalitis;  phlegmonous  pharyngitis;  ton- 
sillar abscess. 

Definition. — An  acute  parenchymatous  inflammation  of  one  or 
both  tonsils,  with  a  strong  tendency  toward  suppuration. 

Causes. — The  affection  is  most  common  in  youth  and  early  adult 
life,  and  is  greatly  influenced  by  rheumatic  diathesis,  exposure  to 
cold  and  wet,  inhalation  of  foul  air,  and  previous  attacks.  It  is 
14 


2IO  •   ACUTE   TONSILLITIS 

probably  due  to  infection;  and  enlarged  tonsils  are  a  predisposing 
factor. 

Symptoms. — The  onset  is  more  or  less  sudden  with  rigors,  rise  of 
temperature,  102°  to  io4°F.,  later  reaching  io5°F.,  full  frequent  pulse, 
100  to  120,  headache,  thirst,  pain  and  swelling  at  the  angle  of  the 
jaw,  difficult  and  intensely  painful  deglutition,  difficult  breathing, 
increased  saUvation,  sometimes  dribbling  from  the  mouth,  muffling 
of  the  voice,  and  often  impaired  hearing  and  earache.  Inspection 
reveals  marked  swelling  and  congestion  of  the  mucous  membrane 
of  the  fauces  and  pharynx.  One  or  both  tonsils  will  be  seen  to  be 
enormously  swollen  and  projecting  toward  the  median  line.  The 
surface  is  covered  with  small,  yellowish  points  which  closely  resemble 
patches  of  false  membrane,  but  close  examination  will  show  them  to 
be  distended  follicles  from  which  cheesy,  foul-smelling  pellets  may  be 
expelled. 

If  suppuration  is  imminent,  the  throat  becomes  more  painful  and 
throbbing  in  character,  the  constitutional  reaction  becomes  more 
severe,  and  fluctuation  may  be  obtained.  Breathing  is  extremely 
difficult  and  relief  is  afforded  when  rupture  occurs  either  spontane- 
ously or  as  the  result  of  a  sudden  effort  at  coughing  or  vomiting. 

The  disease  lasts  from  three  to  seven  days,  terminating  in  resolution 
or  in  suppuration. 

Diagnosis. — This  is  usually  not  difficult,  but  it  may  be  impossible 
on  a  first  examination  to  decide  between  tonsilUtis,  Vincent's  angina, 
and  diphtheria;  hence  cultures  should  be  made  in  doubtml  cases. 
In  such  doubtful  cases  it  is  always  a  good  plan  to  lose  no  time,  but 
to  inject  antitoxin  at  once,  without  waiting  for  the  development 
of  the  bacteria;  then  if  the  case  should  afterward  prove  to  be  diph- 
theria, you  have  done  the  best  thing,  and  if  it  should  be  proved 
not  to  be  diphtheria,  no  harm  has  been  done. 

Prognosis. — As  a  rule  the  disease  ends  favorably.  Suffocation 
may  occasionally  occur,  especially  in  weak  children;  this  is  more 
likely  where  a  "double  quinsy"  causes  obstruction. 

Treatment. — See  above  under. Diagnosis.  Rest  in  bed  and  liquid 
diet  are  the  first  indications.  Calomel,  gr.  v  (0.3  gm.),  and  sodium 
bicarbonate,  gr.  v  (0.3  gm.),  should  be  administered  immediately, 
followed  in  six  or  eight  hours  by  a  saline  cathartic.  Sodium  salicy- 
late, gr.  X  to  XV  (0.6  to  I  gm.)  or  cinchonidine  salicylate,  gr.  v  (0.3 
gm.),  should  then  be  given  every  two  hours  until  six  doses  have 
been  taken.     The  following  is  useful  for  adults  and  rheumatic  cases: 


HYPERTROPHY   OF   THE   TONSILS  211 

I^.     Acidi  salicylici 3ij  8  gm. 

Sodii  bicarbonatis 5jss  6  gm. 

Glycerini 5j  32  c.c. 

Aquse  menthse  piperitae.q.s.  ad  5iv  ad  120  c.c. 

M.  S. — One  tablespoonful  every  two  or  three  hours. 

If  the  febrile  reaction  is  very  great,  tincture  of  aconite  may  be  em- 
ployed in  very  small  doses,  but  if  it  is  contraindicated  internally, 
for  any  reason,  it  may  be  diluted  with  glycerin  and  painted  over  the 
affected  parts.  In  advanced  cases  the  following  will  be  found  of 
value : 

I^.     Tincturas  ferri  chloridi f  3ij  8  c.c. 

Glycerini q.  s.  ad  f  5ij  ad    60  c.c. 

M.  S. — Teaspoonful  every  two  hours,  undiluted.     Not  to  be 
followed  by  food  for  one  hour. 

Among  the  other  remedies  useful  in  this  condition  are  the  am- 
moniated  tincture  of  guaiac,  sodium  benzoate,  salol,  and  phenacetin. 
Ice  pellets  in  the  mouth  will  sometimes  afford  great  relief,  opium 
may  be  necessary  at  times. 

Locally,  ice  or  heat  may  be  applied  to  the  angles  of  the  jaw.  The 
mouth  should  be  kept  as  clean  as  possible  by  means  of  Dobell's  solu- 
tion and  peroxide  of  hydrogen.  Painting  of  the  tonsils  with  nitrate 
of  silver  solution  (gr.  xl  to  f§j)  is  recommended.  Scarification  of 
the  diseased  structures  is  sometimes  very  beneficial.  The  applica- 
tion of  a  solution  of  cocaine  (10  per  cent.)  may  be  of  benefit.  The 
occurrence  of  suppuration  will  necessitate  the  employment  of  hot 
applications  and  early  incision,  preferably  at  the  upper  and  free  side 
of  the  gland,  near  the  soft  palate.  When  the  acute  symptoms  have 
subsided,  copper  sulphate  solution  (gr.  xx  to  f§j),  or  Monsel's 
solution  diluted  (f3j  to  Bj)  should  be  applied  to  hasten  shrinkage 
of  the  glands. 

HYPERTROPHY  OF  THE  TONSILS 

Causes. — Enlargement  of  the  tonsils  may  occur  as  the  result  of 
repeated  acute  attacks  of  inflammation,  but  may  arise  independently. 
It  is  most  common  in  children.  It  may  consist  of  hypertrophy  of 
the  glandular  structure  itself,  the  connective  tissue,  or  both.  The 
consistency   depends   on   the    quantity   of   fibrous   tissue   present. 


212  ESOPHAGITIS 

Catarrhal  inflammation  and  adenoid  growths  of  the  naso-pharynx 
are  common  accompaniments. 

Symptoms. — Enlarged  tonsils  are  always  predisposed  to  inflam- 
mation and  may  remain  unnoticed  until  such  a  condition  arises. 
Inquiry  will  elicit  the  information  that  the  patient  breathes  almost 
constantly  with  the  mouth  open,  snores  during  sleep,  is  subject  to 
night -terrors,  has  difficulty  in  swallowing,  and  is  mentally  dull. 
The  voice  is  usually  thick  and  of  a  nasal  quality,  hearing  is  impaired, 
and  the  face  has  a  stupid  expression.  Development  may  be  inter- 
fered with,  resulting  in  narrowing  of  the  anterior  nares,  contrac- 
tion of  the  superior  dental  arch,  elevation  of  the  hard  palate,  and  the" 
formation  of  the  "chicken-breast,"  so-called,  the  round  or  barrel 
chest,  and  the  funnel  breast.  There  is  fetor  of  the  breath  and 
impairment  of  the  special  senses.  Cough  and  stuttering  are  rather 
common. 

Treatment. — The  enlarged  glands  and  any  pharyngeal  adenoids 
should  be  removed  by  a  surgical  operation,  after  which,  measures 
should  be  employed  to  correct  the  faulty  development.  Fresh 
air,  exercise,  proper  diet,  tonics,  etc.,  will  be  of  great  benefit. 

DISEASES  OF  THE  ESOPHAGUS 

ESOPHAGITIS 

Acute  inflammation  of  the  esophagus  may  result  from  the  swallow- 
ing of  corrosive  liquids,  lodgment  of  foreign  bodies,  diphtheria,  and 
small-pox.  Chronic  inflammation  of  the  esophagus  results  from 
venous  obstruction,  such  as  follows  valvular  heart-disease  and 
cirrhosis  of  the  liver. 

S5nnptoms. — The  principal  manifestations  are  pain  beneath  the 
sternum  and  difficulty  in  swallowing.  There  is  a  copious  mucoid 
secretion  which  may  be  regurgitated  or  passed  into  the  stomach. 
After  destructive  inflammation  the  resulting  cicatricial  changes 
may  eventually  lead  to  obstruction. 

Treatment. — Nothing  can  be  done  to  aid  in  the  cure  of  the  local 
condition.  Demulcents,  ice,  and  liquid  diet  may  be  employed, 
but  if  deglutition  is  painful,  it  is  best  to  resort  to  rectal  feeding. 

ESOPHAGEAL  OBSTRUCTION 

Functional  obstruction  of  the  esophagus  or  esophagismus  is  an 
hysterical  condition  which  is  most  frequently  observed  in  women 


CANCER   or   THE   ESOPHAGUS  2 1 3' 

past  middle  life.  It  may  occur  also  in  chorea,  epilepsy,  and  hydro- 
phobia. Male  hypochondriacs  are  sometimes  affected.  The  con- 
dition is  manifested  by  difficulty  in  swallowing  (which  is  spasmodic 
in  character),  choking,  and  regurgitation  of  food.  It  may  be  excited 
by  liquid  as  well  as  solid  food.  It  is  distinguished  from  other  con- 
ditions of  the  esophagus  by  the  paroxysmal  character  of  the  obstruc- 
tion, the  absence  of  emaciation,  the  history,  age,  and  sex  of  the 
patient,  and  the  ease  with  which  a  bougie  is  passed. 

Treatment. — The  systematic  passage  of  the  esophageal  bougie 
combined  with  appropriate  measures  for  the  relief  of  the  underly- 
ing neurotic  condition  generally  results  in  cure.  Care  must  be 
taken  not  to  produce  ulceration  by  the  too-frequent  employment 
of  instruments. 

Organic  obstruction  of  the  esophagus  may  be  due  to  the  presence 
of  a  foreign  body  in  the  lumen  of  the  tube,  a  contracting  cicatrix 
such  as  follows  ulceration,  corrosives,  acute  esophagitis,  tumors  of 
the  esophageal  wall,  such  as  cancer  and  rarely  polyps,  and  external 
tumors,  including  aneurysm,  enlarged  lymphatic  glands,  and  medias- 
tinal growths.  It  is  manifested  by  slowly  increasing  dysphagia, 
which  is  in  turn  followed  either  by  regurgitation  of  the  food  or  dila- 
tation of  the  esophagus  above  the  point  of  obstruction.  Pain  and 
emaciation  are  constant,  and  it  is  impossible  to  pass  a  bougie.  A 
discharge  of  blood  and  mucus  is  common,  after  such  attempts  in 
cancerous  obstruction.  Death  is  nearly  always  the  termination 
from  starvation  or  exhaustion. 

Treatment. — Rectal  alimentation  will  be  necessary  to  support  the 
patient  and  opium  may  be  required  to  relieve  pain.  In  cicatricial 
obstructiori.  bougies  may  be  employed,  but  in  other  forms  surgical 
treatment  will  be  required.  The  outlook  is  unfavorable  except 
in  cicatricial  obstruction. 

CANCER  OF  THE  ESOPHAGUS 

Description. — It  is  usually  primary,  and  is  more  frequent  in  males 
than  in  females.  The  type  is  generally  epithelioma.  The  tumor 
most  frequently  affects  the  middle  and  lower  third  of  the  esophagus. 
The  mucous  membrane  is  first  attacked;  this  ulcerates,  then  may 
follow  stenosis,  with  hypertrophy  of  the  walls  and  dilatation  of  the 
tube  above  the  cancer.  Perforation  may  occur,  affecting  neighboring 
viscera  or  vessels. 


214  DISEASES   OF   THE   STOMACH 

Symptoms  and  Diagnosis. — Dysphagia,  stenosis,  regurgitation  of 
food,  vomiting  of  blood  and  mucus  with  fragments  of  the  cancer, 
may  all  be  present.  Pressure  symptoms  may  occur.  Cachexia, 
emaciation,  and  pain,  in  males  past  middle  life,  accompanied  with 
regurgitation  of  blood  and  food,  should  make  the  physician  suspect 
cancer. 

Prognosis. — The  disease  is  invariably  fatal.  Emaciation  is 
progressive,  and  the  patient  dies  from  asthenia  or  from  sudden 
perforation  of  the  ulcer. 

Treatment. — Medical  treatment  is  only  palHative.  Milk  and 
liquids  may  be  swallowed,  but  sooner  or  later  rectal  feeding  is 
required.  Morphine  may  be  given  for  the  pain.  The  best  treat- 
ment is  undoubtedly  gastrostomy,  which  may  not  only  prolong  the 
patient's  life,  but  also  save  a  great  deal  of  suffering. 

DISEASES  OF  THE  STOMACH 

DIAGNOSTIC  TECHNIQUE 

External  Examination. — Normally,  the  greater  portion  of  the 
stomach  (three-fourths)  occupies  the  upper  left  quadrant  of  the 
abdomen,  the  remaining  one-fourth  lying  to  the  right  of  the  median 
line.  The  cardiac  orifice  Hes  behind  the  sternal  attachment  of  the 
sixth  or  seventh  costal  cartilages  on  the  left  side,  while  the  pylorus 
is  situated  on  the  right  side  and  above  the  umbiHcus.  In  a  moder- 
ately distended  stomach,  the  highest  part  of^the  fundus  is  about 
the  fifth  interspace  in  the  nipple  line,  and  the  lowest  border  is  i  to 
2  inches  above  the  umbilicus  in  men,  and  iK  to  3  inches  above  the 
same  point  in  women.  To  determine  these  boundaries  it  is  often 
necessary  to  inflate  the  stomach  with  air,  after  which  the  ordinary 
methods  of  physical  diagnosis,  inspection,  palpation,  percussion, 
and  auscultation  may  be  employed.  Traube's  half-moon  space  is 
an  area  on  the  left  side  of  the  trunk,  bounded  above  by  the  upper 
edge  of  the  sixth  rib  as  far  as  the  axillary  line,  on  the  right  side  by 
liver  dullness,  on  the  left  side  by  splenic  dullness,  and  below  by  the 
costal  arch.  When  the  stomach  is  empty  and  distended  a  tympanitic 
note  is  obtained  over  it  by  percussion,  but  when  full,  it  yields  a  flat 
note.  A  pleural  effusion  on  the  left  side  may  also  render  this  area 
flat  to  percussion.  Leichfensiern's  pulmono-hepatic  angle  is  the  angle 
that  exists  at  the  junction  of  the  lower  edge  of  the  left  lobe  of  the 


DIAGNOSTIC   TECHNIQUE  215 

liver,  and  the  lower  border  of  the  left  lung.  Its  apex  lies  behind  the 
sixth  rib,  below  the  apex  beat.  The  lung  occupies  it  only  during 
deep  inspiration,  and  it  is  bisected  by  the  pleural  space.  The  angle 
is  constantly  maintained  and  filled  in  by  the  stomach.  The  outline 
of  the  stomach  may  be  better  determined  by  having  the  patient 
take  in  rapid  succession  the  two  portions  of  a  Seidlitz  powder,  and 
then  proceeding  with  the  examination. 

Internal  Examination. — To  examine  the  stomach  contents  it  is 
necessary  to  administer  a  test-meal  of  definite  quantity  and  quality, 
and  to  withdraw  it  after  a  fixed  time  has  elapsed.  The  digestive 
changes  are  then  noted  and_ deductions  made  as  to  the  state  of 
function  of  the  stomach. 

Boas  and  Ewald's  test-meal  consists  of  an  ordinary  roll  weighing 
9  drams  (35  gm.),  and  10  ounces  (300  c.c.)  of  water,  or  weak  tea  with- 
out milk  or  sugar.  This  is  preferably  given  for  breakfast,  when 
the  stomach  is  empty.  It  is  removed  at  the  end  of  one  hour,  and 
ordinarily  from  20  to  40  c.c.  should  be  the  quantity  withdrawn. 

Leuhe-Riegel  test-meal  consists  of  beef -soup,  13.3  ounces  (400  gm.), 
beefsteak,  6.6  (200  gm.),  bread,  1.6  (50  gm.),  and  water  6.6  (200 
c.c).  The  contents  of  the  stomach  after  this  meal  should  be 
removed  at  the  end  of  four  hours. 

In  removing  the  stomach  contents  it  is  best  to  employ  a  soft, 
flexible,  red  rubber  tube,  open  at  the  inner  end,  or  provided  with 
lateral  openings  like  a  Nelaton's  catheter,  the  length  of  which  is 
is  about  3  feet  (95  cm.).  The  distance  from  the  incisor  teeth  to  the 
fundus  is  about  2  feet  (60  to  65  cm.),  and  the  stomach  tubes  in 
common  use  are  marked  at  this  point  on  the  tube.  To  introduce  it, 
the  tube  should  be  moistened  with  water  and  passed  well  back  into 
the  pharynx,  after  which  the  patient  is  directed  to  swallow,  and  the 
tube  is  pushed  on  very  gently.  In  withdrawing  the  contents  it 
is  best  to  employ  siphonage,  using  a  definite  quantity  of  water  so 
as  to  allow  of  its  deduction  in  the  chemical  examination. 

Contra-indications  to  the  use  of  the  stomach-tube.  These  are 
well  summarized  by  Greene  as  follows: 

"The  following  conditions  usually  forbid  the  use  of  the  tube  in 
those  not  habituated  to  its  use:  (a)  Extreme  weakness  and  exhaustion 
from  whatever  cause,  (b)  Advanced  myocarditis,  (c)  Recent  hemateme- 
sis  or  tarry  stools,  (d)  Advanced  arteriosclerosis  or  past  cerebral 
hemorrhage,  {e)  Pregnancy.  (/)  Aortic  aneurysm,  (g)  Terminal 
pulmonary  tuberculosis  especially  if  hemoptysis  has  occurred,    {h) 


2l6  DISEASES    OF   THE    STOMACH 

High  grades  of  emphysema.  Furthermore,  in  elderly  persons  of 
apoplectic  build  and  tendency  the  first  passage  of  the  tube  usually 
involves  an  amount  of  straining  and  congestion  that  is  extremely 
dangerous.  These  restrictions  need  only  apply  to  hemorrhagic  cases 
and  aneurysm  in  those  habituated  to  the  use  of  the  tube." 

For  the  first  thirty  to  forty-five  minutes  of  gastric  digestion  lactic 
acid  predominates,  but  at  the  end  of  an  hour  it  is  entirely  replaced 
by  free  hydrochloric  acid,  which  exists  in  quantities  varying  from 
0.15  to  o. 2  per  cent,  after  a  light  meal  to  0.2  to  0.33  per  cent,  after  an 
abundant  meal. 

To  test  for  free  acids  it  is  common  to  employ  filter  paper  which 
has  been  soaked  in  a  solution  of  Congo-red.  This  turns  blue  in 
the  presence  of  free  acids.  Tropeolin  may  be  used  in  the  same  man- 
ner, paper  soaked  with  it  turning  brown  under  similar  circumstances. 
These  do  not  dijfferentiate,  however,  between  the  mineral  acids  and 
the  organic  acids. 

Reaction  of  the  stomach  contents  is  important  from  a  clinical  stand- 
point, and  should,  therefore,  always  be  obtained.  Acidity  of  the 
gastric  contents  from  0.15  to  0.2  per  cent,  is  normal,  and  is  due  to 
hydrochloric  acid;  this  condition  is  called  euchlorhydria.  A  greater 
percentage  than  this  constitutes  hyperacidity  or  hyperchlorhydria  and 
is  common  in  neurasthenia,  hysteria,  ulcer  of  the  stomach,  gastric 
dilatation,  locomotor  ataxia,  etc.  Subacidity  or  hypochlorhydria 
refers  to  a  deficiency  in  the  mineral  acid  although  acids  of  fermenta- 
tion may  be  present.  It  is  encountered  in  gastric  cancer,  neurasthe- 
nia, hysteria,  gastric  neuroses,  anemia,  chronic  gastritis,  chronic 
diseases  of  gall-bladder,  pancreas,  etc.  Anachlorhydria  denotes 
absence  of  free  hydrochloric  acid;  it  is  found  in  gastric  cancer  neu- 
rasthenia, hysteria,  chronic  gastritis,  etc. 

Free  hydrochloric  acid  may  be  ascertained  by  Guenzburg's,  Boas\ 
or  Toepfer's  test.  The  reagent  used  by  Guenzburg  consists  of  phloro- 
glucin,  30  gr.  (2  gm.),  vanillin,  15  gr.  (i  gm.),  and  absolute alcohoL 
I  ounce  (30  c.c).  It  must  be  kept  in  a  dark  bottle.  The  gastric, 
contents  should  be  filtered  and  a  few  drops  of  this  solution  added  to 
the  filtrate.  The  mixture  is  evaporated  to  dryness,  a  beautiful  rose- 
red  tinge  at  the  edge  indicating  free  hydrochloric  acid.  This  test 
is  extremely  delicate  and  will  detect  i  part  of  hydrochloric  acid  in 
20,000  parts  of  water.  Boas'  reagent  is  composed  of  resorcin,  75  gr. 
(5  gm.),  white  sugar,  45  gr..(3'  gm.),  and  dilute  alcohol,  33^^  ounces 
(100  CO.).     It  is  applied,  iti  the  same  manner  as  the  preceding,  the 


DIAGNOSTIC   TECHNIQUE  217 

hydrochloric  acid  being  indicated  by  a  purple-red  color.  Toepfer's 
reagent  is  a  0.5  per  cent,  alcoholic  solution  of  dimethyl-amidoazo- 
benzol.  One  or  2  drops  added  to  5  c.c.  of  the  gastric  filtration  will 
turn  the  mixture  a  bright  cherry-red  in  the  presence  of  free  hydro- 
chloric acid. 

Neither  Guenzburg's  nor  Boas'  test  responds  to  organic  acids, 
nor  is  it  interfered  with  by  acid  salts  or  peptones. 

To  determine  the  total  acidity  of  the  gastric  contents,  the  most 
convenient  method  is  to  add  i  drop  of  a  i  per  cent,  solution  of  phenol- 
phthalein  to  10  c.c.  of  the  gastric  filtrate  and  neutralize  this  mixture 
with  a  decinormal  solution  of  sodium  hydrate  from  a  Mohr's  burette. 
A  red  coloration  of  the  filtrate,  which  fails  to  disappear  on  shaking, 
indicates  complete  neutralization.  The  number  of  cubic  centi- 
meters of  the  sodium  hydrate  required  is  read  from  the  scale  and  then 
multiplied  by  ten  to  obtain  the  percentage  of  total  acidity,  for  in- 
stance, if  4  to  6  c.c.  (the  usual  quantity),  were  employed  for  10  c.c. 
of  the  filtrate,  the  percentage  of  total  acidity  would  be  40  to  60. 
The  quantity  of  free  hydrochloric  acid  may  easily  be  obtained  (when 
it  exists  alone)  if  it  is  remembered  that  i  c.c.  of  the  alkaline  solution 
is  equivalent  to  0.00365  gm.  of  hydrochloric  acid.  Guenzburg's 
reagent  is  applicable  in  this  test  as  in  the  preceding  for  qualitative 
purposes.  Toepfer's  reagent  may  also  be  employed  in  a  similar 
manner  for  the  same  purpose.  A  i  per  cent,  aqueous  solution  of 
alizarin  is  sometimes  used;  neutralization  of  the  gastric  filtrate 
containing  a  few  drops  of  it,  by  the  decinormal  sodium  hydrate 
solution  is  evidenced  by  a  violet  color.  In  all,  it  is  customary  to 
employ  10  c.c.  of  the  filtrate,  using  the  reagents  to  test  for  the  res- 
ence  of  acid  until  it  is  completely  neutralized  by  the  alkali  solution. 

Lactic  acid  niay  be  detected  by  Uffelmann's  test.  Ufelmann's 
reagent  is  composed  of  a  4  per  cent,  solution  of  carbohc  acid,  10  c.c, 
distilled  water,  20  c.c,  and  the  official  neutral  ferric  chloride  solution, 
I  drop.  The  mixture  should  be  freshly  made  and  should  possess 
an  amethyst-blue  color.  The  presence  of  lactic  acid  will  be  indicated 
by  a  canary-yellow  color  on  mixing  the  reagent  with  the  gastric 
filtrate.  This  test  will  detect  i  part  of  lactic  acid  in  20,000  parts 
solution.  The  presence  of  lactic  acid  in  any  marked  degree  is  al- 
most pathognomonic  of  gastric  cancer;  but  its  absence  does  not 
deny  the  existence  of  cancer.  It  may  also  be  found  in  gastric  dilata- 
tion. 

Butyric  acid  is  distinguished  by  its  characteristic  odor  on  boiling 


2l8  DISEASES   OF   THE   STOMACH 

the  filtrate  and  by  its  brownish  yellow  reaction  with  Uffelmann's 
solution.  It  may  also  be  separated  in  drops  by  the  addition  of  cal- 
cium chloride.  When  not  due  to  ingestion  of  fats,  butyric  acid  may 
be  found  in  the  same  conditions  as  lactic  acid. 

Acetic  acid  may  be  recognized  by  its  odor  or  by  the  dark  red  color 
it  produces  with  ferric  chloride  solution.  To  obtain  this,  it  is  first 
extracted  from  the  filtrate  by  ether,  then  evaporated,  and  the  residue 
dissolved  in  distilled  water,  after  which  it  is  neutrahzed  by  a  solution 
of  sodium  carbonate.  Acetic  acid  may  be  found  after  the  ingestion 
of  alcohol,  otherwise  it  has  the  same  significance  as  lactic  acid. 

Alcohol  resulting  from  yeast  fermentation  in  the  stomach  may  be 
detected  by  Lieben's  iodoform  test.  The  gastric  contents  should  be 
distilled,  and  a  small  quantity  of  liquor  potassae  added  to  the  distillate; 
a  few  drops  of  a  solution  of  iodine  and  potassium  iodide  are  then 
added,  and  if  alcohol  is  present  iodoform  will  be  precipitated  from 
the  mixture.  (Use  i  part  of  the  distillate,  2  of  Hquor  potassas,  and 
50  of  the  solution  of  iodine  and  potassium  iodide.) 

Propeptone  and  peptone,  the  products  of  albumin  digestion,  yield 
a  purplish-red  color  on  the  addition  of  Fehling's  solution. 

Rennet  or  Lah  ferment  is  detected  by  its  action  on  raw  milk.  A 
few  drops  of  the  gastric  filtrate  should  be  added  to  3.6  drams  (10  c.c.) 
of  raw  milk  and  the  mixture  placed  in  a  chamber  at  an  average  tem- 
perature of  ioo°F.  The  presence  of  the  ferment  is  indicated  by 
coagulation  of  the  milk.  Rennet  does  not  exist  primarily  as  such, 
but  as  rennet-zymogen,  which  has  no  effect  on  milk.  It  may  be 
converted  into  rennet  by  the  addition  of  hydrochloric  acid  or  cal- 
cium chloride.  Its  absence  may  denote  carcinoma,  atrophic  gastritis, 
or  achylia  gastrica. 

Pepsin  is  usually  present  in  the  filtrate,  in  which  hydrochloric 
acid  has  been  detected,  but  if  it  is  absent  it  should  be  supplied  in 
sufficient  quantity  and  slices  of  coagulated  white  of  egg  added  to  the 
mixture.  The  whole  is  placed  in  an  oven  at  ioo°F.,  and  in  the  pres- 
ence of  pepsin,  dissolution  of  the  eggs  should  occur  within  an  hour. 

Starch  products  in  the  filtrate  will  be  indicated  by  the  deep  blue 
color  produced  by  contact  with  iodine  or  with  Lugol's  solution  which 
consists  of  iodine  i,  potassium  iodide  2,  and  distilled  water  200.  In 
the  absence  of  such  reaction  it  may  be  inferred  that  starch  digestion 
has  been  complete. 

SahlVs  Desmoid  Reaction. — This  is  a  test  for  gastric  digestion 
without  the  use  of  the  stomach-tube.     Methylene  blue  (or  potassium 


ACUTE   GASTRITIS  219 

iodide  or  salicylic  acid)  are  used.  A  small  quantity  is  placed  in  a  little 
rubber  bag  which  is  then  securely  closed  with  pliable  catgut.  The 
patient  swallows  this  immediately  after  a  full  meal,  being  careful 
not  to  bite  it.  If  the  stomach  functions  are  normal,  the  methylene 
blue  will  impart  to  the  urine  a  greenish-blue  color  in  about  sixteen 
hours;  if  hyperacidity  be  present,  the  reaction  occurs  about  five  or 
six  hours  later;  in  hypoacidity,  not  for  twenty-four  hours.  (The 
time  may  vary  according  to  the  make  of  catgut.)  The  elimination 
of  the  methylene  blue  is  delayed  in  advanced  cardiac  and  renal  dis- 
ease, and  also  in  enteritis. 

The  rate  of  absorption  is  indicated  by  the  period  necessary  for  free 
iodine  to  appear  in  the  saHva  after  the  ingestion  of  a  capsule  contain- 
ing o.  I  gm.  of  potassium  iodide.  Normally  ten  or  fifteen  minutes  is 
sufficient.  Filter  paper,  impregnated  with  starch,  is  used  as  the 
reagent;  and  a  blue  reaction  indicates  the  appearance  of  the  iodine 
in  the  saliva. 

The  motor  power  of  the  stomach  may  be  ascertained  in  several  ways : 
(i)  Withdrawal  of  the  gastric  contents  six  to  seven  hours  after  the 
ingestion  of  the  Leube-Riegel  test-meal  should  demonstrate  no  solid 
residue  if  the  motor  power  is  normal.  (2)  Salicyluric  acid  should 
appear  in  the  urine  within  one  hour  after  the  ingestion  of  1 5  gr.  (i  gm.), 
of  salol,  under  normal  conditions.  The  acid  is  detected  by  the  violet 
color  produced  on  contact  with  a  10  per  cent,  solution  of  ferric 
chloride. 

Microscopic  examination  of  the  stomach  contents  may  reveal 
the  presence  of  starch-cells,  yeast-cells,  muscle-fibers,  shreds  of 
mucous  membrane,  epithelium,  Oppler-Boas  bacillus,  pus-cells,  blood 
corpuscles,   and  various  bacteria. 

ACUTE   GASTRITIS 

Synonyms.' — Simple  gastritis;  gastric  fever;  gastric  catarrh;  acute 
dyspepsia. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous  mem- 
brane of  the  stomach. 

Causes. — It  may  arise  from  overloading  the  stomach,  or  from  the 
presence  in  the  stomach  of  undigested  or  indigestible  foods,  alcoholic 
beverages  in.  excess,  irritating  medicines,  such  as  the  bromides,  iodides, 
and  arsenic,  and  corrosive  poisons  such  as  the  mineral  acids,  corro- 
sive sublimate,  copper,  carbolic  acid,  etc.  It  may  also  be  due  to 
exposure  to  cold  and  wet  and  the  infectious  fevers. 


220  ACUTE    GASTRITIS 

Pathological  Anatomy.— The  mucous  membrane  of  the  stomach 

is  swollen  and  engorged  and  covered  with  a  grayish,  semi-transparent 
tenacious  mucus  of  alkaline  reaction.  Mucoid  degeneration  and 
cloudy  swelling  of  the  glandular  cells  are  present.  The  pyloric 
region  shows  the  most  marked  inflammation.  In  toxic  cases,  erosions 
are  observed  everywhere  throughout  the  mucosa;  the  gastric  tubules 
are  destroyed  in  great  numbers;  and  the  submucous,  muscular,  and 
serous  coats  may  show  decided  destructive  changes. 

Sjrmptoms. — Under  ordinary  circumstances,  acute  gastric  catarrh 
is  manifested  by  loss  of  appetite,  heavily  coated  tongue,  thirst,  fetor 
of  the  breath,  nausea,  sometimes  vomiting,  first  of  undigested  food, 
then  of  viscid  mucus,  and  finally  bilious  matter,  moderate  fever, 
headache,  flashes  of  heat  with  sensations  of  burning  in  the  palms 
of  the  hands  and  soles  of  the  feet,  abdominal  pain,  tenderness,  and 
distress,  eructations,  vertigo,  fullness  of  the  head,  and  constipation 
or  diarrhea.  Herpes  may  appear  about  the  mouth  toward  the  end 
of  an  attack.  Jaundice  may  be  present  as  may  also  slight  fever. 
The  urine  is  scanty  and  contains  urates  and  pigment.  Examination 
of  the  stomach  contents  shows  a  deficiency  in  hydrochloric  acid  and 
an  excess  of  lactic  and  fatty  acids,  mucus,  and  undigested  food. 
Digestion  is  considerably  prolonged. 

In  toxic  gastritis,  immediately  or  very  shortly  after  the  poison  is 
swallowed  there  ensues  a  deadly  nausea,  followed  by  rapid  and  per- 
sistent vomiting,  first  of  the  stomach  contents,  afterward  shreds  of 
mucous  membrane  and  blood  clots.  Anxiety  and  depression,  a 
weak,  rapid  pulse,  slow  and  shallow  respiration,  cold,  clammy  skin, 
intense  burning  pain  and  heat  in  the  epigastrium,  thirst  with  burning 
in  the  fauces  and  gullet,  exhaustive  purging,  shrunken  features,  and 
collapse  follow. 

Diagnosis. — Simple  cases  may  resemble  the  onset  of  one  of  the 
infectious  fevers,  but  the  absence  of  other  symptoms  than  those 
referable  to  the  stomach,  within  twenty-four  to  forty-eight  hours  will 
establish  the  diagnosis.  In  toxic  cases,jthe  history  and  the  sudden 
and  severe  symptoms  will  indicate  poisoning,  and  the  stains  on  the 
lips,  mucous  membrane,  face,  or  clothing  may  determine  the  charac- 
ter of  the  poison,  for  instance:  A  blackish  eschar  points  to  sulphuric 
acid,  a  yellowish  eschar  to  nitric  acid,  widespread  softening  and 
maceration  of  the  tissues  to  caustic  potash,  whitish  or  glazed  stains 
to  corrosive  sublimate,  whitish  and  corrugated  stains  to  carbolic  acid, 
and  yellowish  white  scars  changing  to  grayish  brown  to  chromic  acid. 


ACUTE    GASTRITIS  221 

Prognosis. — In  mild  cases,  the  duration  is  about  one  week  and 
the  termination  is  favorable,  although  complete  recovery  may  be 
slow.  The  toxic  form  is  very  grave.  Many  perish  from  shock. 
In  cases  not  immediately  fatal,  death  may  occur  from  exhaustion 
and  starvation  incident  to  the  destructive  changes.  Cases  that 
eventually  recover  are  always  affected  with  gastric  disturbances  of 
varying  degree. 

Treatment. — The  stomach  should  be  placed  at  rest.  When  the 
stomach  is  overloaded  ipecac  should  be  given  by  the  mouth  or 
apomorphine  hydrochloride,  gr.  }i  (0.008  gm.),  should  be  admin- 
istered hypodermically.  If  vomiting  has  already  begun  large 
draughts  of  hot  water  should  be  given.  Active  purgation  by 
calomel,  gr.  v  to  x  (0.32  to  0.65  gm.),  and  sodium  bicarbonate,  gr. 
V  (0.32  gm.),  followed  by  an  ounce  of  magnesium  sulphate  or  a  full 
dose  of  Hunyadi  Janos  water,  is  of  great  value  in  most  cases.  Frac- 
tional doses  of  calomel  are  sometimes  preferred.  After  the  stomach 
and  bowels  have  been  thoroughly  emptied,  feeding  should  be 
resumed,  beginning  with  the  most  bland  food.  Nux  vomica,  pepsin, 
or  papoid  may  then  be  administered. 

The  following  is  an  excellent  stomachic  sedative: 

I^.     Sodii  bicarb 5iij  12  gm. 

Bismuth,  subnitrat 5ij  8  gm. 

Aq.  chloroformi f  Siij  90  c.c. 

M.  et  adde 

Aq.  menthae  pip f  5j  30  c.c. 

Aq.  lauro-cerasi f  gij  60  c.c. 

M.  S. — Tablespoonful  four  times  a  day. 
Another  excellent  formula  after  the  acute  symptoms  have  subsided 
is: 

I^.     Strychninae  sulphat gr.  ss  0.03  gm. 

Acid,  hydrochlorici  dil f5iv  15 -O    c.c. 

Glycerini f §j  30.0    c.c. 

Tinct.  card,  comp f§ss  150    c.c. 

Aq.  lauro-cerasi f§j  30.0    c.c. 

M.  S. — One  teaspoonful,  diluted,  four  times  daily. 

In  toxic  gastritis,  morphine  sulphate  should  be  given  hypodermic- 
ally  at  once  and  repeated  if  necessary.  Strychnine  and  atropine 
will  be  required  in  most  cases  to  sustain  the  circulation.  Demulcents 
and  milk  and  lime-water  should  be  freely  given.  Ice  internally  and 
locally  affords  great  relief.     Bismuth  subnitrate,  gr.  xx  to  xxx  (1.3 


222 


ACUTE   GASTRITIS 


to  2  gm.),  every  hour  is  beneficial.  The  stomach  should  be  emptied 
of  its  contents  immediately  by  means  of  an  emetic  (apomorphine 
hydrochloride)  or  lavage. 

In  all  cases  of  poisoning,  the  indications  as  laid  down  by  Tanner, 
are:  (i)  Lose  no  time.  (2)  Use  the  best  remedy  obtainable  at  once. 
(3)  Get  rid  of  the  poison.  (4)  Stop  its  action.  (5)  Remedy  the 
mischief  already  done.  And  (6)  Fight  against  the  tendency  to 
death. 

If  seen  early  the  appropriate  antidote  should  be  administered. 
The  following  table  (compiled  chiefly  from  Potter's  Therapeutics, 
Materia  Medica  and  Pharmacy),  will  be  found  of  value  for  ready 
reference  in  this  condition. 


Irritant  and  Corrosive  Poisons 


Poison 


Antidotes 


Acid,  carbolic. 


Acid,  oxalic  and  "salts 
of  lemon,"  or  of 
"sorrel." 

Acids,  mineral 

Alkalies 

Ammonia 

Arsenic 

Corrosive  sublimate 

Iodine 

Metallic  salts 

Phenol 

Phosphorus 

Silver  nitrate 

Soda,  or  "caustic  pot- 
ash."    "Lye."  : 


Magnesium  or  sodium  sulphate;  alcohol;  liquor  calcis  sac- 
charatus;  vinegar.  Wash  outistomach  with  alcohol  and 
water.     Give  hypodermic   of   apomorphine  hydrochloride. 

Calcium  carbonate  or  hydrate  (as  lime-water,  chalk,  whiting, 
wall-plaster,  in  water),  or  magnesia.  Avoid  potassium 
and  sodium  carbonates  and  bicarbonates.  Bland  mucilagi- 
nous drinks,  and  poultices  to  the  abdomen. 

Alkalies,  as  sodium  carbonate  or  bicarbonate,  magnesia,  or 
chalk,  soap,  whiting,  wall-plaster,  in  water.  Albumin, 
flour,  milk,  starch,  olive  oil,  to  protect  the  mucous  membrane. 
Avoid  water  in  sulphuric  acid  cases. 

Acids,  diluted,  especially  the  vegetable  acids,  as  vinegar, 
lemon-juice,  etc.  Albumin,  milk,  gelatin.  Oils  to  protect 
the  mucous  surfaces. 

Vinegar,  lemon-  or  orange-juice,  any  vegetable  acid,  followed 
by  demulcents  to  protect  the  mucous  surfaces.  When  in- 
haled, give  vapor  of  acetic  or  hydrochloric  acids  or  chlorine- 
water  by  inhalation,  the  two  latter  forming  the  chloride. 

Freshly  prepared  solution  of  ferric  hydroxide;  dialyzed  iron; 
apom9rphine  as  an  emetic. 

Albumin,  white  of  egg  (4  gr.  sublimate  require  white  of  i 
egg),  flour,  milk;  this  should  be  followed  by  stomach-tube, 
or  emetic. 

Starch,  albumin,  flour,  sodium  or  potassium  carbonates  and 
bicarbonates. 

Albumin,  milk,  magnesia,  starch,  soap.  Oils  and  other 
demulcents.  Sodium  or  potassium  carbonate  or  bicarbonate. 
Five  per  cent,  solution  of  borax  in  milk.  Lavage  of  stomach. 
Emetics  and  cathartics. 

See  Acid,  carbolic. 

Potassium  permanganate;  turpentine,  old  and  acid,  con- 
taining oxygen;  hydrated  magnesia  in  linseed  tea.  Avoid 
oils,  fats,  and  milk. 

Solution  of  common  salt  in  demulcent  drink. 

Ohve  oil,  demulcents,  vinegar,  lemon-juice;  and  stimulants 
hypodermically. 


CHRONIC   GASTRITIS  22$ 

CHRONIC  GASTRITIS 

S3mon3mis. — Chronic  gastric  catarrh;  chronic  dyspepsia. 

Definition. — A  chronic  catarrhal  inflammation  of  the  stomach 
with  thickening  of  the  coats,  enfeeblement  of  the  musculature, 
atrophy  of  the  gastric  glands,  changes  in  the  gastric  juice,  and 
increased  secretion  of  mucus. 

Achylia  gastrica  is  a  term  applied  to  the  absence  of  free  or  com- 
bined hydrochloric  acid  and  pepsin  and  rennin.  It  is  often  asso- 
ciated with  chronic  gastritis,  atrophy,  and  carcinoma,  but  it  may  also 
occur  independently. 

Causes. — Repeated  attacks  of  acute  gastritis;  dyspepsia,  neglected 
or  long  continued;  habitual  and  excessive  use  of  spirituous  Hquors, 
tea,  coffee,  and  the  free  use  of  ice- water  during  and  between  meals; 
improperly  prepared  and  unsuitable  food;  irregularity  of  meals  and 
imperfect  mastication;  excessive  tobacco-chewing;  anemia;  diseases 
of  the  heart,  lungs,  pleura,  liver,  or  kidneys,  producing  chronic 
congestion  of  the  stomachic  vessels;  cancerous  or  other  degenerative 
diseases  of  the  stomach. 

Pathological  Anatomy. — The  mucous  membrane  is  of  a  brownish 
or  slate  color,  elevated  into  ridges  from  hypertrophy,  the  result  of 
constant  congestion;  the  peptic  glands  first  increase  in  size,  then 
undergo  granular  change,  resulting  in  atrophy  of  their  cells.  The 
mucous  membrane  is  covered  with  a  thick,  alkaline,  tenacious  mucus. 
The  tubules  may,  in  some  places,  be  distended  by  secretion,  and  in 
other  places  contracted  by  the  excess  of  connective  tissue  surround- 
ing them.  Ewald  describes  the  minute  anatomy  as  that  of  a 
parenchymatous  and  interstitial  inflammation,  which  may  lead  to 
such  widespread  degeneration  of  the  glandular  elements  so  that 
ultimately  scarcely  a  trace  of  secreting  tissue  remains.  These 
changes  may  affect  the  entire  organ  or  be  limited  to  portions  of  the 
stomach;  they  are  most  marked  at  the  pyloric  end. 

Symptoms. — The  persistent  and  manifold  symptoms  of  indiges- 
tion are  present,  such  as  loss  of  appetite;  disagreeable  feeling  of 
gnawing  and  at  times  fullness  in  the  stomach;  tenderness  in  the 
epigastrium,  but  slightly  influenced  by  eating;  prominence  of  the 
epigastrium,  from  distention  by  decomposing  gases;  and  occasional 
nausea  and  vomiting  of  undigested  foods  after  meals,  or  of  color- 
less fluid  when  the  stomach  is  empty.  The  vomitus  often  contains 
a  large  amount  of  mucus,  and  its  reaction  may  be  neutral  or  acid; 


224  "     CHRONIC    GASTRITIS 

in  the  latter  event,  the  acidity  is  due,  not  to  hydrochloric  acid  (which 
is  diminished)  but  to  organic  acids  produced  by  fermentation. 

Early  morning  vomiting  of  glairy  mucus  and  saliva,  coating  of 
the  tongue,  constant  thirst,  burning  at  the  pit  of  the  stomach  or 
under  the  sternum  (heartburn),  pain  after  eating,  and  constipation 
are  common.  In  long-standing  cases  the  circulation  is  feeble;  there 
is  depression  of  spirits  often  amounting  to  melancholia;  and  vertigo 
and  sleeplessness  are  present.  Follicular  pharyngitis  often  accom- 
panies the  condition.  The  imperfect  digestion  leads  eventually 
to  loss  of  flesh.  The  urine  is  high-colored  and  contains  phosphates, 
urates,  and  the  oxalate  of  lime  in  excess.  I  An  examination  of  the 
gastric  contents  will  show  a  diminution  in  hydrochloric  acid  and 
pepsin,  and  rennin,  and  a  large  quantity  of  mucus,  and  often  sarcinae 
ventriculi.  In  severe  cases  there  may  be  absence  of  hydrochloric 
acid,  pepsin,  mucus,  and  epithelium;  and  the  gastric  contents  be 
made  up  chiefly^of  undigested  food  and  bacteria. 

Diagnosis. — Chronic  gastritis  may  be  readily  recognized,  if  the 
history  and  symptoms  are  fully  considered.  In  many  instances 
the  stomach  disturbance  is  secondary  to  some  visceral  disease, 
which  may  be  ascertained  by  a  careful  examination. 

Gastric  cancer  may  be  distinguished  by  the  early  absence  of  hydro- 
chloric acid,  and  the  presence  of  large  quantities  of  lactic  acid  and 
the  Boas-Oppler  bacillus  in  the  stomach  contents,  vomiting  of  a 
persistent  character,  containing  blood  in  the  advanced  stages,  enlarge- 
ment at  the  pylorus,  dilatation  of  the  stomach,  and  cachexia. 

Gastric  ulcer  differs  from  chronic  gastritis  in  that  there  is  hyper- 
acidity, localized  pain  and  tenderness  worse  after  eating,  and 
hematemesis. 

Dyspepsia  has  to  be  distinguished  from  chronic  gastritis,  and  the 
following  table  from  Wheeler  and  Jack  may  aid  in  diagnosing  between 
the  two  conditions: 

Chronic  gastritis  Dyspepsia 


Less     severe;      tenderness     is     usually 
absent. 
Not  raised. 


Pain  is  often  severe  with  diffuse  epigastric 

tenderness. 
Fever. — Temperature        sometimes       slightly 

raised. 
Thirst. — Often  a  marked  symptom.  t  Absent. 

Vomiting. — Frequently    occurs    especially    in   Vomiting   is   not   frequent_  except   aftet 

the   morning.     Lactic,   butyric,   and  acetic      certain  foods,  then  relief  is  obtained. 

acids   often   present.     Pain  is   not   usually! 

relieved  by  vomiting. 


CHRONIC    GASTRITIS 


225 


Chronic  gastritis 


Dyspepsia 


Causes. — Usually  the  constant  introduction 
of  irritants,  such  as  alcohol  in  excess,  abuse 
of  tea,  niorphin,  etc. 

Tongue,  etc.,  is  furred,  red  at  the  tip  and  edges. 
The  lips  are  cracked,  and  the  gums  spongy 
and  red. 

Morbid  Anatomy. — Stomach  is  much  thick- 
ened, the  mucous  membrane  is  often  much 
atrophied  and  fibrous  in  structure.  It 
presents  a  rough  mammilated  appearance 
with  suppurating  points,  localized  vascular 
areas,  and  hemorrhagic  erosions. 
Note. — Though  the  membrane  is  thickened, 
there  is  marked  atrophy  of  the  glandular 
elements. 


See  page  240.  Often  there  is  no  oVjvious 
cause  and  the  best  dietetic  treatment 
may  fail  to  cure. 

Tongue  broad,  flabby,  and  indented  b'y 
the  teeth.  Gums  are  soft  and  anemic. 
Lips  are  not  usually  fissured. 

In  pure  dyspepsia  these  changes  are 
not  present.  The  mucous  membrane 
may  be  thickened  and  injected.  The 
muscular  fibers  are  pale,  flabby,  and 
relaxed. 


Prognosis. — With  treatment,  most  of  the  symptoms  may  be 
greatly  relieved  and  in  mild  cases  cure  may  be  affected.  When 
the  mucous  membrane  has  become  atrophied  the  outlook  becomes 
unfavorable. 

Treatment. — The  first  indication  is  the  correction  of  the  indiges- 
tion, which  is  usually  the  most  pronounced  and  distressing  symp- 
tom; this  is  accomplished  by  carefully  regulating  the  amount  and 
character  of  the  food  used,  avoiding  fatty,  saccharine,  and  starchy 
articles  or  highly  seasoned  food  or  stimulants.  A  milk  diet  is  bene- 
ficial, and  to  it  may  be  added  beef  in  small  amounts,  eggs,  oysters, 
and  a  few  fresh  green  vegetables.  It  must  be  remembered,  however, 
that  some  persons  cannot  take  milk;  in  such  cases,  the  addition  of 
lime-water,  some  alkaline  carbonated  water  (such  as  Vichy)  and  a 
pinch  of  salt,  will  overcome  the  difficulty.  Skimmed  milk,  butter- 
milk, or  fermented  milk  may  be  more  palatable  to  the  patient,  at 
any  rate  for  a  time.  If  beef  is  allowed,  it  had  better,  for  a  time,  be 
in  the  form  of  "Salisbury  steaks"  made  of  lean  beef  shaped  into 
flattened  cakes  and  broiled.  This,  or  whatever  other  articles  of 
diet  are  allowed,  should  be  taken  an  hour  or  more  after  sipping  slowly 
a  half  pint  (250  c.c.)  of  water  at  110°  to  i5o°F.  The  hot  water 
should  also  be  taken  before  retiring.  The  patient  should  be  advised 
against  overeating  and  also  against  imperfect  mastication  and 
hurrying  over  his  meals. 

The  constipation  should  be  relieved  by  the, use  of  laxative  mineral 
waters,  such  as  Bedford,  Saratoga,  and  Hunyadi  Janos  waters,  or 
an  artificial  Carlsbad  salt,  which  may  be  made  as  follows:  Sodium 
sulphate,  50  parts;  sodium  bicarbonate,  6;  sodium  chloride,  3;  take 
one  teaspoonful  dissolved  in  a  glass  of  water. 

IS 


2  26  CHRONIC    GASTRITIS 

Or  the  following  may  be  used: 

I^.     Magnesii  sulphat gr.  Ix  to  cxx    4.0  to  8  gm. 

Sodii  et  potass,  tartrat gr.  xxx  to  Ix   2  .  o  to  4  gm. 

•  Acid  tartaric gr.  xx  1.3  gm. 

M.  S. — Dissolve  in  a  glass  of  water  and  drink  one  hour  before 
breakfast. 

An  excellent  purgative  and  promoter  of  stomachic  peristalsis  is: 

I^.     Fluidextract  cascarae  sagradas  f  Bj  30  c.c. 

Glycerini f  gss  15  c.c. 

Tin ct.  nucis  vomicae fBss  150.0. 

Aq.  chloroformi f  §  j  30  c.c. 

M.  S. — One  or  two  teaspoonfuls  after  meals,  well  diluted. 

For  the  purpose  of  cleaning  the  stomach  of  the  tenacious  mucus 
as  well  as  for  its  stimulating  action  on  the  glands,  lavage  or  irriga- 
tion of  the  stomach,  with  lukewarm  water  is  valuable.  The  water 
may  be  medicated  with  a  solution  of  salt,  sodium  bicarbonate,  or 
boric  acid.  Ewald  considers  the  morning,  when  the  stomach  is 
empty,  the  preferable  time  for  lavage. 

Those  patients  who  object  to  lavage  obtain  relief  from  the  sys- 
tematic drinking  of  3>^  to  i  pint  (250  to  500  c.c.)  of  hot  water  an 
hour  before  meals,  as  mentioned  above. 

The  irritable  condition  of  the  mucous  membrane  is  at  times  greatly 
benefited  by  the  use  of  bromide  of  strontium,  gr.  xv  (i  gm.),  well 
diluted,  before  meals.  For  the  anorexia  in  chronic  gastritis, 
Hemmeter  gives: 

I^.     Strychninae  sulphatis gr.  H  0.02  gm. 

Acidi  hydrochloric!  diluti.  .    3v  20.0    c.c. 

Elixir  gentianae  .... q.  s.  ad   §vj  24.0    c.c. 

M.  S. — A  tablespoonful  in  a  wineglass  of -water,  after  meals. 

In  the  presence  of  some  morbid  condition  of  the  mucous  mem- 
brane the  solution  of  the  arsenite  of  potassium  (Fowler's  solution), 
TTLj  to  ij  (0.06  to  0.12  c.c),  before  meals,  or  bismuth  subnitrate, 
gr.  x  to  xx  (0.65  to  1.3  gm.),  one  hour  before  or  two  or  three  hours 
after,  meals  will  be  of  value.  The  following  combination  will  be 
found  very  useful: 


PEPTIC  ulcer;  gastric,  and  duodenal  227 

I^.     Sodii  bicarb 5iv  15.0      gm. 

Bismuth,  subnitrat 5vj  24.0      gm. 

Aqu£e  chloroformi f  5  iij  90 .  o      c.c. 

M.  et  adde 

Aquae  lauro-cerasi f  B iij  90.0      c.c. 

Strychninae  sulphat gr.  j  0.065  g^- 

M.  S. — Two  teaspoonfuls  at  mealtime  in  a  little  water. 

Silver  nitrate,  gr.  ^i  (0.016  gm.),  or  silver  oxide,  gr.  ss  to  j  (0.032 
to  0.065  g^O  i^  pi^lj  before  meals,  or  dilute  hydrochloric  acid,  lUx 
to  XV  (0.6  to  I  c.c.)  in  water,  before  meals  may  also  be  employed. 
When  pain  is  severe,  opium,  belladonna,  or  cocaine  may  occasionally 
be  required  internally  and  belladonna  plaster  may  be  applied  over 
the  stomach.  If  pain  and  nausea  are  severe,  the  following  may  be 
given : 

I^.     Bismuthi  subcarbonatis gr.  x  0.65  gm. 

Acidi  hydrocyanici  diluti TTlv  0.32  c.c. 

Liquoris  opii  sedativi TTlv  0.32  c.c. 

Mucilaginis  tragacanthae 5j  4-0    c.c. 

Aquae  menthae  pip eritae  q.  s.  ad  §j  32.0    c.c. 

M.   S. — To  be  taken  half  an  hour  before  food,  or  when  in 
pain. 

To  aid  digestion,  acids,  pepsin,  pancreatin,  papoid,  and  bitters 
are  of  value,  the  following  being  an  excellent  prescription: 

I^.     Pepsini  (cryst.) gr.  Ix  4.0      gm. 

Acid  hydrochlorici  dil f5iv  15 -O      c.c. 

Glycerini fSiv  15.0      c.c. 

Strychninae  sulphat gr.  ss  o .  032  gm. 

Aquae  chloroformi,  q.  s.  ad  fSiij  ad  90.0      c.c. 

M.  S. — One  teaspoonful  at  mealtime  in  a  little  water. 

In  addition  to  medicinal  measures,  there  should  be  prescribed 
mental  and  physical  rest,  gentle  systematic  exercises,  change  of 
environment,  etc. 

PEPTIC  ULCER;  GASTRIC,  AND  DUODENAL 

Sjmonym. — Simple  or  round  ulcer. 

Definition. — A  round  or  oval,  usually  single,  sharply  defined  loss 
of  tissue  involving  the  mucous  membrane  and  one  or  more  layers 
of  the  wall  of  the  stomach  or  duodenum;  characterized  by  gastric 
pain,  disorders  of  digestion,  hyperacidity,  and  vomiting  of  blood. 


2  28  PEPTIC  ulcer;  gastric,  and  duodenal 

Causes. — The  important  etiological  factors  are  early  adult  life, 
female  sex  (for  gastric  ulcer),  traumatism,  chlorosis,  and  anemia. 
The  exciting  cause  may  be  an  embolus  or  thrombus,  or  self -diges- 
tion of  the  stomach  wall.  Two  prime  factors  are  said  to  be:  (i) 
feeble  nutrition  of  part  of  the  mucous  membrane;  and  (2)  the  action 
on  this  area  of  an  excessively  acid  gastric  juice,  by  which  the  mucous 
membrane  is  "digested  out."  In  the  duodenum  it  occurs  more 
frequently  in  males,  and  is  sometimes  associated  with  extensive 
superficial  burns,  and  tuberculosis. 

Pathological  Anatomy. — In  the  majority  of  cases  the  ulcer  is 
solitary  and  is  situated  on  the  posterior  wall  of  the  stomach  near 
the  pylorus;  or  in  the  first  part  of  the  duodenum,  within  1}^  inches 
of  the  pylorus.  In  a  typical  case  there  is  a  circular  hole,  with  a 
sharp  border  in  the  mucous  coat,  the  sides  converging  in  the  muscular 
coat,  coming  to  a  point  in  the  serous  coat,  thus  forming  a  funnel- 
shaped  lesion.  This  appearance  is  most  marked  in  recent  cases. 
As  the  ulcer  advances  it  becomes  elliptical  and  irregular,  varying 
from  3^  to  J-^  inch  in  diameter.  The  edges,  however,  seldom  become 
irregular.  Perforation  may  occur.  Blood-vessels  are  constantly 
eroded,  producing  profuse  hemorrhage  and  subsequent  hematemesis. 
Connective  tissue  replaces  the  ulcerated  area  in  the  process  of  healing. 

Symptoms. — Indigestion  and  its  various  manifestations  are  com- 
monly present.  The  characteristic  symptoms  are  pain,  localized 
tenderness,  vomiting,  hematemesis,  hyperacidity,  and  sometimes 
an  enlargement  in  the  region  of  the  pylorus.  The  pain  is  paroxysmal 
in  character,  comes  on  in  from  ten  to  thirty  minutes  after  eating 
but  may  be  delayed  for  two  or  three  hours,  and  is  aggravated  by 
the  taking  of  food,  especially  hot,  cold,  indigestible,  or  spicy  sub- 
stances. While  usually  located  in  the  "pit"  of  the  stomach  it  may 
radiate  to  the  back  and  limbs.  A  burning,  gnawing  pain  may  also 
be  present  between  the  paroxysms  of  gastralgia.  The  symptoms 
are  intermittent,  and  there  may  be  long  periods  of  freedom  from  pain; 
the  pain  is  relieved  by  food.  Tenderness  on  pressure  is  rather  con- 
stant, and  patients  wear  the  waist-band  rather  low;  it  usually  may 
be  elicited  at  a  point  an  inch  or  two  above  the  umbilicus.  Pressure 
must  be  made  with  care  or  perforation  may  occur.  Vomiting  is 
common.  It  may  appear  immediately  after  eating,  when  the  ulcer 
is  near  the  cardiac  orifice,  but  when  located  near  the  pylorus  it 
usually  comes  on  an  hour  after  eating.  The  vomitus  is  usually  very 
acid,  and  consists  of  undigested  food  and  mucus.     Hemorrhage  into 


PEPTIC  ulcer;  gastric,  and  duodenal  229 

the  stomach  from  erosion  of  a  blood-vessel  causes  vomiting  of  large 
quantities  of  bright  red  blood  and  the  passage  of  dark  blood  from 
the  bowels;  such  a  hemorrhage  is  quite  a  characteristic  symptom  of 
ulcer  of  the  stomach.  It  occurs  in  about  50  per  cent,  of  cases. 
Examination  of  the  stomach  contents  will  show  an  increase  in  the 
hydrochloric  acid.  Anemia,  loss  of  weight,  anorexia,  and  general 
failing  of  health  accompany  the  condition.  The  condition  is  often 
latent,  presenting  no  symptoms  during  life;  a  sudden  and  fatal  hemor- 
rhage (hematemesis)  may  occur,  and  the  ulcer  be  found  at  the 
autopsy. 

Diagnosis. — Gastralgia  resembles  gastric  ulcer  as  regards  hyper- 
acidity and  the  paroxysmal  pains.  It  differs  in  the  absence  of  dys- 
peptic symptoms  between  the  attacks,  hematemesis,  and  localized 
tenderness  and  enlargement.  Von  Leube  has  shown  that  the 
application  of  an  electric  current  during  digestion  causes  a  cessation 
of  pain  in  gastralgia,  but  not  in  gastric  ulcer  and  cancer. 

Gastric  cancer  may  be  distinguished  from  gastric  ulcer  in  that  it 
occurs  at  a  later  period  in  life,  has  a  more  rapid  course,  the  cachexia 
and  emaciation  are  more  prominent,  the  pain  is  more  constant,  the 
growth  is  palpable,  the  vomit  has  a  "coffee-grounds"  appearance, 
and  there  is  absence  of  hydrochloric  acid  and  presence  of  lactic  acidi. 

Intercostal  neuritis  accompanying  chronic  gastritis  may  lead  to  an 
error  in  diagnosis,  but  the  absence  of  localized  tenderness  above  the 
umbilicus,  hyperacidity  of  the  gastric  contents,  and  hematemesis 
will  serve  to  make  a  distinction. 

Hyperchlorhydria  is  attended  only  by  an  increase  in  the  hydro- 
chloric acid  and  pain  which  is  relieved  by  albuminous  food.  The 
other  symptoms  common  to  gastric  ulcer  are  absent. 

The  gastric  crises  of  locomotor  ataxia -are  sometimes  very  similar 
to  the  pains  of  gastric  ulcer;  but  the  lightning  pains,  ocular  symptoms, 
and  absence  of  knee-jerks  soon  manifest  themselves  in  the  former 
disease. 

The  differentiation  between  gastric  and  duodenal  ulcer  is  often 
impossible.  The  latter  may  be  suspected:  (i)  If  the  pain  occurs 
in  two  to  four  hours  after  eating,  and  is  located  in  the  right  hypo- 
chondrium;  (2)  if  there  is  a  hemorrhage  from  the  bowel  rather  than 
an  hematemesis;  (3)  jaundice  is  more  frequent  in  duodenal  ulcer. 

Prognosis. — Usually  the  ulcer  is  slow  in  forming  and  runs  a  very 
chronic  course,  the  average  duration  being  about  one  year.  Oc- 
casionally it  may  develop   very  suddenly.     It  may  terminate  in 


230  PEPTIC  ulcer;  gastric,  and  duodenal 

perforation  (6  per  cent.),  peritonitis,  fatal  hemorrhage,  or  recovery 
with  cicatricial  formations.  The  mortality  varies  according  to 
different  observers  from  10  to  30  per  cent.  With  proper  treatment 
recoveries  are  frequent.     Relapses  are  not  uncommon  occurrences. 

Treatment. — The  patient  should  be  placed  at  rest  in  bed.  The 
diet  should  consist  of  only  the  most  bland  food,'  preferably  milk 
(i  or  2  ounces  every  two  hours)  and  Hme- water,  beef -juice,  egg- 
albumin,  or  skimmed  milk.  When  feeding  by  the  mouth  induces 
too  much  irritation,  resort  should  be  made  to  rectal  aUmentation. 
An  enema  made  up  of  4  ounces  of  milk,  2  eggs,  a  very  small  quantity 
of  salt,  and  3  drops  of  the  tincture  of  opium,  the  entire  mixture 
being  predigested  by  pancreatin,  is  very  valuable  in  this  connection. 

Severe  hemorrhage  will  indicate  the  injection  of  warm  normal 
salt  solution  into  the  rectum  or  hypodermicaUy,  and  the  adminis- 
tration of  10  drops  of  adrenalin  solution  (i  to  1,000).  Strychnine, 
nitroglycerin,  and  ammonia  may  be  given  to  sustain  the  heart  at 
this  period.  Ergot,  acetate  of  lead,  gr.  j  to  ij  (0.065  to  0.2  gm.), 
gelatin,  tannic  acid,  gr.  xv  (i  gm.),  and  persulphate  or  iron,  gr. 
^  to  3^  (0.0165  to  0.033  g^O;  ^I'e  also  advised  to  control  the  hemor- 
rhage. An  ice-bag  over  the  stomach  and  small  pellets  of  ice  inter- 
nally may  be  of  value.  Feeding^by^the  mouth  should  be  suspended 
when  there  is  hematemesis. 

The  hyperacidity  may  be  overcome  by  large  doses  of  bicarbonate 
of  sodium  and  calcined  magnesia  every  four  hours.  Bismuth  sub- 
nitrate  and  belladonna  may  be  useful.  In  the  presence  of  consti- 
pation, Carlsbad  salt  should  be  employed.  For  relief  of  the  pain, 
morphine-may  be  necessary. 

The  medicines  of  special  value  in  this  condition  are  Fowler's 
solution,  TTtj  .to_ij  (0.06  to  0.13  c.c),  every  five  hours;  smbnitrate 
of  bismuth,  (gr.  xx  to  xxx  (1.3  to  2  gm.),  combined  with  sodium 
bicarbonate,  gr.  v  (0.32  gm.),  three  times  daily;  silver  nitrate,  gr. 
M  to  3^  (0.016  to  0.022  gm.)  every  four  hours;  and  silver  oxide,  gr. 
ss  (0.032  gm.).  Iron  and  arsenical  preparations  are  indicated  for 
the  constant  anemia. 

I^.     Ferri  albuminatis gr.  ij  0.13    gm. 

Sodii  arsenat •  •  •   gr.  Mo  o •  003  gi^- 

M.     Ft.  pil.  or  capsule. 
S. — One  three  times  daily. 

The  occurrence  of  perforation  requires  prompt  surgical  inter- 
vention.    Operative  treatment  has  also  been  advised  for  the  cure 


CANCER   OF   THE    STOMACH  23 1 

of  cases  of  nonperforating  ulcer  in  which  the  hemorrhages  recur,  or 
in  which  there  has  been  a  copious  single  hemorrhage. 

CANCER  OF  THE  STOMACH 

S3nionyms. — Gastric  cancer;  gastric  carcinoma. 

Definition. — A  malignant  growth,  occurring  for  the  most  part  at 
the  pyloric  extremity  of  the  stomach,  making  constant  progress, 
destroying  the  gastric  tissues  and  infecting  the  lymphatic  glands; 
characterized  by  disorders  of  digestion,  pain,  vomiting,  marked 
anemia  and  cachexia,  and  terminating  in  all  cases  by  the  death  of 
the  patient. 

Causes. — Cancer  of  the  stomach  usually  develops  in  patients 
past  forty  years  of  age.  The  sexes  are  about  equally  affected. 
Heredity  is  said  to  be  a  factor  in  some  cases  and  prolonged  irritation 
such  as  accompanies  the  scars  of  old  ulcers  and  chronic  gastritis  may 
be  a  predisposing  cause. 

Pathological  Anatomy. — Next  to  the  uterus  the  stomach  is  the 
most  frequent  site  of  cancer.  The  growth  is  nearly  always  primary; 
though  secondary  cancer  of  the  stomach  may  occasionally  occur. 
Following  Tyson:  "Every  variety  of  cancer  is  found  in  the  stomach, 
in  the  following  order  of  frequency:  (i)  Cylinder-celled  epithelioma, 
■most  frequent  at  the  pylorus.  (2)  Medullary  or  soft  cancer,  most 
frequent  in  the  smaller  curvature.  (3)  Scirrhus,  at  the  pylorus  and 
in  the  smaller  curvature,  causing,  especially,  stenosis  of  the  pyloric 
orifice.  (4)  Colloid,  diffuse  infiltration  with  a  tei^dency  to  spread 
to  the  peritoneum  and  adjacent  organs.  (5)  Melanotic.  (6) 
Squamous  epithelioma,  near  the  cardia. 

"All  the  forms  start  from  the  gland  cells  of  the  mucous  membrane. 
The  medullary  variety  is  prone  to  ulcerate  and  to  form  extensive 
fungoid  ulcerated  surfaces,  from  which  there  may  or  may  not  be 
hemorrhage.  It  may  be  associated  with  scirrhus.  While  nodular 
outgrowths  are  usual,  the  cancerous  tissue  may  infiltrate  the  walls, 
producing  diffuse  thickening."  About  80  per  cent,  of  gastric  cancers 
are  found  at  the  pylorus.  Those  portions  of  the  stomach  remote 
from  the  growth  are  comparatively  healthy.  The  growth  usually 
begins  in  the  tubules.  The  lymphatic  glands  adjacent  to  the 
stomach  enlarge  '  as  the  growth  progresses  and  secondary  cancers 
result. 

•     The  condition  may  give  rise  to  dilatation  of  the  stomach,  or  to 
reduction  in  size  of  the  stomach  with  dilatation  of  the  esophagus; 


232  CANCER  OF  THE  STOMACH 

the  stomach  may  be  altered  in  shape,  or  displaced;  adhesion  may 
occur  with  adjacent  organs  or  with  the  anterior  abdominal  wall ; 
perforation  and  peritonitis  may  also  result. 

Symptoms. — The  manifestations  of  indigestion  are  present  from 
the  onset.  The  majority  of  cases  have  vomiting,  occurring  imme- 
diately after  eating,  if  the  disease  is  at  the  cardiac  orifice,  and  some 
hours  after  if  located  at  the  pylorus ;  if  much  dilatation  of  the  stomach 
develops,  the  vomiting  occurs  after  several  days.  The  rejected 
matter  is  food  in  various  stages  of  digestion,  associated  frequently 
with  black  grumous  masses  of  altered  blood  and  tissues.  Hemat- 
emesis  is  frequent,  rarely  profuse,  usually  oozing  of  blood  altered 
into  a  dark  brown  or  black  color — "coffee-ground"  vomit — in  which 
Teichmann's  hemin  crystals  may  be  obtained;  or  the  oozing  blood 
passes  into  the  intestinal  canal,  causing  tarry  stools.  The  blood  is 
sometimes  so  small  in  quantity  that  a  microscopic  or  chemical 
examination  is  required  to  discover  it. 

Absence  of  hydrochloric  acid  in  the  stomach  is  a  very  constant 
observation  in  gastric  cancer.  Boas  and  Stewart  (D.  D.),  in  1895, 
found  by  the  use  of  the  test-meal  (flour  soup)  that  lactic  acid  was 
always  present  in  gastric  cancer,  and  they  were  unable  to  find  this 
acid  in  any  other  stomach  condition.  The  Boas-Oppler  bacillus 
is  also  present. 

Pain  is  constant,  but  is  dull  and  heavy  in  character,  increased 
by  pressure  and  food,  and  may  radiate  to  the  back.  A  tumor  is 
found  in  three-fourths  of  the  cases  in  the  epigastric  region  which 
does  not  move  with  inspiration.  Edema  of  the  ankles  is  a  common 
phenomenon  in  gastric  cancer,  occurring  as  early  as  the  third  month 
and  may  proceed  to  general  anasarca.  Marked  anemia,  debility, 
emaciation,  and  cachexia  are  constant  symptoms.  Jaundice  fre- 
quently occurs  and  the  liver  may  be  enlarged.  There  is  involve- 
ment of  the  lymphatic  glands  in  the  supraclavicular  and  inguinal 
regions  particularly.  All  the  symptoms  of  gastric  dilatation  (page 
234)  are  present.  The  urine  may  contain  excess  of  indican,  and  is 
sometimes  albuminous;  and  there  may  be  irregular  fever. 

Diagnosis. — The  age,  history  (with  a  previous  ulcer),  the  presence 
of  a  palpable  tumor  loss  of  weight,  hematemesis  of  "coffee-ground" 
material,  the  absence  of  free  hydrochloric  acid,  and  the  presence 
of  lactic  acid  and  Boas-Oppler  bacillus  in  the  stomach  contents,  and 
the  cancerous  cachexia  are  the  important  points  in  the  diagnosis. 

Chronic  gastric  catarrh  is  characterized  only  by  aggravated  dys- 


CANCER  OF  THE  STOMACH  233 

pepsia  and  possesses  none  of  the  distinctive  features  of  gastric 
cancer. 

Gastric  ulcer  differs  from  gastric  cancer  in  the  age  of  the  patient, 
the  character  of  the  pain,  the  hemorrhage,  and  the  stomach  contents. 

Cancer  of  the  pancreas  is  generally  attended  by  jaundice  and 
diarrhea  with  fatty  or  oily  stools. 

Pernicious  anemia  has  no  tumor,  less  cachexia,  and  a  more  pro- 
nounced diminution  in  the  number  of  the  red  blood  cells;  the  latter 
often  fall  below  1,000,000  to  the  cubic  millimeter  in  anemia,  while  in 
gastric  cancer  they  rarely  fall  below  2,000,000.  As  F.  P.  Henry 
tersely  puts  it:  "In  cancer  of  the  stomach  the  reduction  in  the 
number  of  red  corpuscles  does  not  keep  pace  with  the  cachexia;  in 
anemia  the  cachexia  does  not  keep  pace  with  the  destruction  of  red 
corpuscles." 

Abdominal  tumors  of  other  structures  differ  in  that  most  of  them 
in  this  region  move  on  inspiration.  Aneurysm  of  the  abdominal 
aorta  is  distinguished  by  its  expansile  pulsation.  A  pulsation  may 
be  communicated  to  a  scirrhus  at  the  pylorus,  but  if  the  patient  is 
directed  to  rest  upon  the  hands  and  feet,  the  gastric  tumor  falls 
away  from  the  aorta  and  the  pulsation  ceases. 

Prognosis. — The  disease  is  invariably  fatal;  sometimes  an  early 
recognition  of  the  disease  followed  by  prompt  and  complete  removal 
by  a  competent  surgeon  may  prolong  life. 

Treatment. — Medical  treatment  is  only  palliative,  and  is  therefore 
unsatisfactory;  it  is  directed  largely  toward  maintaining  the  patient's 
strength  by  suitable  foods.  Ordinary  diet  soon  becomes  inadequate 
and  irritating,  and  predigested  foods  have  to  be  used.  Peptonized 
milk  may  be  prepared  by  adding  5  gm.  of  extract  of  pancreas  and 
15  gr.  of  sodium  bicarbonate  to  a  pint  of  milk,  placing  the  mixture 
in  a  compartment  at  a  temperature  of  ioo°F.,  from  which  it  is  re- 
moved in  one  hour.  Peptonized  beef,  peptonized  eggs,  and  similar 
foods  may  be  employed.  Should  the  stomach  become  unretentive, 
or,  in  the  presence  of  other  contra-indications,  resort  should  be  had 
to  rectal  alimentation.  The  administration  of  dilute  hydrochloric 
acid  aids  digestion  and  prevents  fermentation;  and  much  has  been 
claimed  for  condurango: 

I^.      Strychninse  sulphat gr.  ss  0.032  gm. 

Acid,  hydrochlor.  dil f5iv  15 -O       c.c. 

Inf.  condurango..  .  .q.  s.  ad  foviij     ad    240.0      c.c. 
M.  S. — Tablespoonful  before  meals,  diluted. 


234  GASTRIC   DILATATION 

For  pain,  morphine,  or  the  following  recommended  by  Osier: 

I^.     Morphinas  sulphat gr.  K  0.008  gm. 

Sodii  bicarb gr.  v  0.3      gm. 

Bismuth,  subnitrat gr.  x  0.6      gm. 

M.  S. — Repeated  p.  r.  n. 

Fetor  of  the  breath  may  be  relieved  to  some  extent  by  carbolic 
acid,  gr.  },'i  to  J^  (0.016  to  0.022  gm.),  or  purified  animal  charcoal, 
gr.  X  to  XXX  (0.65  to  2  gm.).  (And  see  page  206.)  Washing  out  of 
the  stomach  an  hour  before  breakfast  will  produce  benefit  by  remov- 
ing the  retained  and  fermented  material  in  that  viscus,  but  it  is  a 
dangerous  procedure,  and  in  the  presence  of  ulceration  perforation 
may  be  produced.     Stimulants  should  be  avoided. 

Surgical  treatment  is  of  value  provided  the  diagnosis  is  made 
early  in  the  course  of  the  disease. 

GASTRIC  DILATATION 

Sjmonym. — Gastrectasis,  or  gastrectasia. 

Definition. — An  abnormal  and  permanent  increase  in  the  capacity 
of  the  stomach,  with  the  walls  either  h3rpertrophied  or  decreased  in 
thickness;  'characterized  by  pronounced  indigestion,  vomiting  of 
partly  digested  and  partly  decomposed  food  at  intervals  of  a  day  or 
two,  and  noisy  moving  of  flatus  within  the  abdomen  (borborygmus). 

Causes. — Stenosis  of  the  pylorus  such  as  results  from  cancer, 
cicatricial  contraction,  hypertrophy  of  the  pylorus,  and  the  pressure 
of  abdominal  tumors  is  the  most  common  cause.  It  may  result 
from  relaxation  of  the  stomach  walls  such  as  follows  habitual  over- 
distention  from  excessive  eating  or  drinking,  and  anemia.  General 
anesthesia  (particularly  chloroform)  seems  to  favor  its  production. 

Pathological  Anatomy. — The  entire  organ  is  dilated  and  its  mus- 
cular wall  is  hypertrophied  in  pyloric  obstruction;  but  in  atonic 
dilatation,  the  muscular  layer  is  thinner  than  normal,  paler  in  color, 
and  presents  signs  of  fatty  degeneration.  The  mucous  membrane 
is  also  pale,  thin,  and  without  rugse. 

Symptoms. — The  characteristic  feature  of  gastric  dilatation  is 
the  vomiting  which  occurs  long  after  meals,  often  at  intervals  of 
several  days.  The  vomitus  is  large  in  amount,  and  consists  of  un- 
digested and  fermented  food  and  a  turbid  liquid.  It  contains  yeast 
cells  and  other  low  forms  of  plant  life.  In  addition  to  vomiting,  the 
symptoms  of  chronic  gastritis  and  of  the  affection  to  which  the  dilata- 
tion is  due  are  very  prominent.     Constipation  is  common. 


GASTROPTOSIS  235 

Physical  signs  of  gastric  dilatation  are:  on  inspection,  abnormal 
prominence  of  the  whole  epigastric  region,  with  a  tumor  in  the 
pyloric  region  which  seems  to  be  connected  with  the  stomach;  per- 
cussion, if  empty,  tympanitic  note  having  a  metallic  quality,  extend- 
ing to  or  below  the  umbilicus;  if  the  stomach  be  filled,  high-pitched 
flat  note;  auscultation,  splashing  and  rumbling  sound,  the  succussion 
sound  being  distinct  if  the  body  be  shaken. 

Diagnosis. — The  peculiar  vomiting  and  the  physical  signs  together 
with  the  history  will  aid  greatly  in  making  a  diagnosis.  The  outline 
of  the  stomach  may  be  mapped  out  by  physical  examination  by 
inflating  the  organ  with  air  or  filling  it  with  liquid.  The  x-vsly  may 
also  be  used.  A  bismuth  solution  is  given  to  produce  a  shadow  in 
the  stomach  after  which  a  skiagraph  is  taken.  According  to  Boas, 
dilatation  is  present  when  the  greater  curvature  of  the  empty  stomach 
is  below  the  umbilicus  and  when  the  greatest  vertical  diameter  of 
the  stomach  is  from  10  to  14  cm.  (4  to  53^  inches). 

Prognosis. — Recovery  is  impossible  in  malignant  pyloric  obstruc- 
tion, but  in  atonic  dilatation  considerable  symptomatic  relief  may  be 
afforded. 

Treatment. — A  ''dry  diet"  should  be  used  exclusively  and  only 
small  quantities  should  be  given  at  a  time.  Fluid  should  be  adminis- 
tered by  rectal  ^enemas.  Washing  out  of  the  stomach  every  night 
before  retiring  should  be  performed.  An  abdominal  bandage  may 
be  of  benefit.  Drugs,  such  as  dilute  hydrochloric  acid,  nitrohydro- 
chloric  acid,  pepsin,  nux  vomica,  creosote,  charcoal,  salol,  and  bis- 
muth, or  betanaphtol  may  be  employed  to  prevent  fermentation. 
Surgical  treatment, 'pyloroplasty  and  gastroenterostomy,  may  be  con- 
sidered in  organic  pyloric  obstruction. 

GASTROPTOSIS 

Definition. — A  displacement  of  the  stomach  downward,  associated 
with  prolapse  of  the  bowel  (enteroptosis  or  Glenard's  disease)  and 
often  the  prolapse  of  the  kidney  (nephroptosis). 

Causes. — The  condition  is  predisposed  to  by  imperfect  develop- 
ment of  the  abdominal  and  other  muscles  and  by  their  early  loss 
of  tension  with  wasting.  Women  are  most  often  affected.  Fre- 
quent pregnancies,  wearing  tight  corsets,  or  other  unyielding 
garments,  and  occupations  which  favor  stooping  postures,  such  as 
sewing,  tailoring,  shoemaking,  etc.,  are  important  factors  in  its 
production.     Relaxation  of  the  abdominal  walls  and  loss  of  abdom- 


236  *  HEMATEMESIS 

inal  fat  from  any  cause  may  give  rise  to  displacement  of  the  stomach. 

Anatomical  Conditions. — The  transverse  colon  is  the  first  organ 
to  prolapse,  and  is  soon  followed  by  the  ascending  colon.  The 
stomach  is  tilted,  its  lower  border  reaching  below  the  umbilicus, 
while  its  lesser  curvature  lies  between  the  ensiform  cartilage  and 
the  tunbilicus.  In  some  cases  the  pyloric  end  is  dow^n  to  or  below 
the  umbilicus,  without  so  much  prolapse  of  the  fundus.  The  right 
kidney  is  displaced  and  often  floating  or  movable.  The  left  kidney 
is  less  often  displaced.  Any  or  all  of  the  conditions  named  may  be 
associated  with  any  of  the  organic  gastric  conditions. 

Sjrmptoms. — The  patient  complains  of  dyspepsia,  abdominal 
distress  and  pain  after  eating,  eructations  of  gases,  anorexia,  various 
nervous  symptoms,  weakness,  and  constipation. 

Physical  Phenomena. — In  the  standing  position  the  lower  part 
of  the  abdomen  projects  and  the  upper  part  sinks  in.  In  the  recum- 
bent position  the  abdomen  shows  a  lateral  extension.  Aortic  pulsa- 
tion is  frequent.  There  is  often  "a  ridge  lying  across  the  abdomen" 
to  be  determined  by  palpation.  Glenard  termed  this  ridge  the 
''cordecolique  transverse"  and  thought  it  was  due  to  a  prolapse  of 
and  partial  occlusion  of  the  transverse  colon.  Other  observers 
think  it  is  the  pancreas  that  is  felt  on  account  of  the  prolapse  of  the 
transverse  colon.  Inflation  of  the  stomach  often  detects  its  pro- 
lapsed position  with  a  lowered  gastric  splashing.  The  x-ray,  with 
the  aid  of  a  bismuth  subnitrate  solution,  will  determine  the  location 
of  the  organ. 

Treatment. — -Abdominal  bandages  or  some  mechanical  apparatus 
may  be  worn  to  help  maintain  the  organ  in  place,  but  the  benefit 
they  produce  is  not  marked.  Surgical  intervention  sometimes 
relieves  the  condition.  In  all  cases,  measures  directed  toward  im- 
proving the  general  health  should  be  employed.  Lavage  is  useful 
in  that  it  serves  to  prevent  dilatation  of  the  stomach. 

HEMATEMESIS 

Synonyms. — Gastric  hemorrhage;  gastrorrhagia;  hemorrhage  of 
the  stomach. 

Causes. — Hematemesis  may  be  due  to  ulcer,  cancer,  cirrhosis 
or  congestion  of  the  liver,  scurvy,  purpura,  hemophiHa,  malaria, 
congestion  of  the  spleen,  chronic  heart  disease,  vicarious  menstrua- 
tion, traumatism,  yellow  fever,  toxic  gastritis,  or  rupture  of  an 
aneurysm  into  the  stomach.     The  condition  is  sometimes  feigned 


HEMATEMESIS  237 

by  hysterical  patients  who  first  swallow  blood  or  some  other  colored 
liquid,  and  then  vomit  it. 

Symptoms. — The  principal  symptom  is  blood,  of  varying  quantity, 
in  the  vomit.  In  ulcer  of  the  stomach  it  is  bright  red,  but  in  cancer, 
the  most  common  cause,  it  has  the  characteristic  "coffee-grounds" 
appearance,  being  dark,  mixed  with  the  food,  and  of  acid  reaction. 
If  the  hemorrhage  is  profuse,  blood  will  appear  in  the  stools.  There 
are  also  present  at  the  time  of  the  loss  of  blood  pallor,  weakness, 
ringing  in  the  ears,  faintness,  and  a  sinking  feeling  at  the  pit  of  the 
stomach. 

^^ Occult  blood,^'  or  "occult  hemorrhage'^  is  the  name  given  to  minute 
quantities  of  blood  found  in  the  feces  by  the  most  delicate  tests 
(microscopic  or  chemical) ;  it  is  sometimes  found  in  ulcer  and  cancer 
of  the  stomach. 

Diagnosis. — The  chief  condition  from  which  hematemesis  is  to 
be  distinguished  is  hemoptysis  (bleeding  from  the  lungs).  The 
following  table  shows  the  chief  differences: 


Hematemesis 

Hemoptysis 

I. 

2. 
3. 

1' 

Previous    history    of    gastric,    hepatic,    or 
splenic  disease. 
Blood  is  vomited. 

Blood  is  dark  colored  and  not  frothy. 
Blood  may  be  mixed  with  food 

I. 

2. 
3. 

4- 
5- 

6. 
7. 

Previous      history      of      pulmonary 

troubles. 

Blood  is  coughed  up. 

Blood  is  frothy  and  bright  red. 

Blood  may  be  mixed  with  sputa. 

5. 

6. 

7. 

Giddiness  or   faintness     usually    precede 
vomiting. 

Nausea  and  weight  in  epigastrium 

Often    followed    by    melena    (black    tarry 
stools). 

Sensation   of   tickling    in  the   throat 

usually  precedes. 

Dyspnea  and  pains  in  the  chest. 

Is  not  usually  succeeded  by  melena. 

Prognosis. — Except  in  case  of  a  ruptured  aneurysm,  hematemesis 
is  seldom  the  direct  cause  of  death.  Hemorrhage  from  the  stomach 
in  the  course  of  gastric  ulcer  or  cancer,  hepatic  cirrhosis,  hemophilia, 
and  the  infectious  fevers  is  an  unfavorable  sign.  The  outcome 
depends  entirely  on  the  underlying  cause. 

Treatment. — Rest  in  bed  is  absolutely  necessary  and  food  should 
be  temporarily  withheld.  Pellets  of  ice  may  be  swallowed  and  ice- 
bags  should  be  placed  over  the  stomach  and  along  the  spine.  In 
some  cases  hot  water  is  equally  beneficial.  Morphine  and  ergotine 
should  be  given  hypodermically.  Monsel's  solution,  ITlj  to  v 
(0.06  to  0.3  c.c),  diluted,  or  adrenalin  chloride  (i  to  1000),  TTtx 
(0.6  c.c),  may  be  administered  by  the  mouth  for  its  hemostatic  effect. 


238  '  GASTRALGIA 

Tannic  acid,  lead  acetate,  and  gelatin  may  also  be  employed  for  the 
sa'me  purpose.  Shock  should  be  treated  as  under  ordinary  circum- 
stances. The  condition  underlying  the  gastric  hemorrhage  should 
receive  attention. 


GASTRALGIA 

Synonyms. — Cardialgia;  gastrodynia;  stomachic  colic;  neuralgia 
of  the  stomach. 

Definition. — A  painful  condition  of  the  stomach,  induced  by 
various  forms  of  irritation;  characterized  by  violent  paroxysms 
of  gastric  pain  and  associated  with  feeble  cardiac  action  and  symp- 
toms of  collapse,  but  independent  of  disturbance  of  the  gastric 
functions. 

Causes. — The  affection  belongs  to  the  group  of  neuralgias.  The 
most  important  factor  in  its  causation  is  general  nervous  depression 
or  neurasthenia;  other  causes  are  gastric  cancer  or  ulcer,  malaria, 
rheumatic  or  gouty  diathesis,  syphiUs,  anemia,  and  certain  articles 
of  diet.  It  occurs  in  chronic  nervous  affections  as  the  so-called  "gas- 
tric crises."  It  is  more  frequently  observed  in  women  than  men,  and 
may  arise  from  worry,  menstrual  disorders,  sexual  excesses,  and  the 
abuse  of  tobacco. 

Symptoms.— Romberg's  description  of  an  attack  may  be  quoted: 
''Suddenly,  or. after  a  feeHng  of  pressure  at  the  precordium,  there  is 
severe  griping  pain  in  the  stomach,  usually  extending  to  the  back, 
with  a  feeHng  of  fainting,  a  shrunken  countenance,  cold  hands  and 
feet,  and  an  intermittent  pulse.  The  pain  becomes  so  excessive  that 
the  patient  cries  out.  The  epigastrium  is  either  puffed  out  Hke  a  ball, 
or  retracted,  with  tension  of  the  abdominal  walls.  There  is  often 
pulsation  in  the  epigastrium.  External  pressure  is  well  borne,  and 
not  unfrequently  the  patient  presses  the  pit  of  the  stomach  against 
some  firm  substance,  or  compresses  it  with  his  hands.  Sympathetic 
pains  often  occur  in  the  thorax,  under  the  sternum,  and  in  the  esoph- 
ageal branches  of  the  pneumogastric,  while  they  are  rare  in  the  exterior 
of  the  body.  The  attack  lasts  from  a  few  minutes  to  half  an  hour  or 
longer;  then  the  pain  gradually  subsides,  leaving  the  patient  much 
exhausted;  or  else  it  ceases  suddenly,  with  eructation  of  gas  or  watery 
fluid,  or  with  vomiting  and  with  a  gentle  soft  perspiration,  or  with 
the  passage  of  reddish  urine." 


GASTRALGIA  239 

Diagnosis. — Myalgia  of  the  abdominal  muscles  is  distinguished 
by  tenderness  on  pressure  over  the  affected  area,  more  constant  pain, 
and  the  absence  of  symptoms  directly  referable  to  the 
stomach. 

Gastric  cancer  is  differentiated  by  the  age,  course,  history,  hemat- 
emesis,  cachexia,  tumor,  anemia,  and  the  constant  character  of  the 
pain. 

Von  Leube  has  shown  that  the  application  of  an  electric  current 
during  digestion  causes  a  cessation  of  pain  in  gastralgia,  but  not  in 
gastric  ulcer  and  cancer. 

Gastric  ulcer  is  attended  by  localized  pain  and  tenderness,  aggra- 
vated by  food  and  external  pressure,  hematemesis,  hyperacidity, 
and  dyspeptic  symptoms. 

In  biliary  colic  the  pain  is  usually  to  the  right  of  the  median  line, 
radiating  to  the  right  and  to  the  right  scapula  and  shooting  toward 
the  right  ilium.     Chills,  fever,  and  jaundice  are  also  present. 

In  renal  colic  the  pain  begins  at  the  kidney  and  radiates  along  the 
corresponding  ureter.     The  pain  is  mostly  posterior. 

Abdominal  colic  is  attended  by  gaseous  distention  and  is  centered 
lower  down  in  the  abdomen. 

Angina  pectoris  is  characterized  by  pain,  which  radiates  from  the 
heart  down  the  left  arm  and  is  accompanied  by  a  sense  of  constriction 
of  the  thorax,  and  a  strong  fear  of  impending  death;  in  angina  pectoris 
the  patient  sits  upright,  in  gastralgia  he  usually  bends  forward  or 
lies  down. 

The  gastric  crises  of  locomotor  ataxia  may  be  recognized  b^'-  the 
concomitant  signs,  the  characteristic  gait  and  pupils,  history,  etc. 

Prognosis. — The  affection  is  not  dangerous  to  life  but  may  persist 
for  an  indefinite  period. 

Treatment. — A  mild  attack  may  be  relieved  by  antipyrine,  gr.  x 
(0.65  gm.),  and  the  application  of  a  hot-water  bag  over  the  stomach. 
Galvanism,  placing  the  anode  over  the  stomach  and  the  kathode 
near  the  spine,  is  often  beneficial.  A  mixture  of  equal  parts  of 
chloroform,  compound  tincture  of  cardamom,  aromatic  spirit  of 
ammonia  and  brandy  is  recommended;  a  teaspoonful  of  this  may  be 
given  every  fifteen  or  thirty  minutes  till  relief  is  experienced.  When 
the  pain  is  very  severe  morphine,  by  hypodermic  injection,  may  be 
necessary;  but  care  must  be  taken  to  avoid  forming  a  morphine  habit. 
In  recurring  attacks  Van  Valzah  recommends: 


240  •  DYSPEPSIA 

I^.     Codeinae gr.  3^  o ,  oi6      gm. 

Ext.  cannab.  indicae gr.  Ho  0.006      gm. 

Atropinae  sulphat gr-  /^oo  0.00032  gm. 

Aconitinae gr.  Moo  0.00016  gm. 

M.     Ft.  capsul.   ■ 

S. — One  every  four  or  six  hours. 

During  the  interval,  the  underlying  cause  should  be  ascertained 
and  appropriate  treatment  instituted.  As  nerve-exhaustion  is 
usually  the  cause,  rest,  regulated  diet,  exercise  of  moderate  degree, 
fresh  air,  nerve  tonics,  etc.,  should  be  prescribed. 

DYSPEPSIA 

Synonyms. — Gastric  indigestion;  heartburn;  pyrosis. 

Definition. — A  functional  disorder  of  the  stomach,  with  deficient 
secretion  in  either  the  quantity  or  quality  of  the  gastric  juice; 
characterized  by  disorders  of  the  functions  of  digestion  and  assimila- 
tion, and  the  presence  of  various  nervous  symptoms. 

Causes. — Among  the  principal  etiological  factors  may  be  men- 
tioned nervous  depression  from  worry  and  fatigue,  sedentary  habits, 
imperfect  mastication,  ingestion  of  large  quantities  of  food,  un- 
changed diet,  heredity,  neurasthenia,  hysteria,  and  the  female  sex, 

Sjnnptoms. — The  appetite  is  capricious,  perverted,  or  lost;  diges- 
tion is  difficult,  there  is  a  sense  of  distention  and  weight  in  the  epi- 
gastrium; and  there  is  acidity  of  the  gastric  contents  from  decom- 
position of  the  albuminoids.  Heartburn,  flatulency,  regurgitation  of 
portions  of  partly  digested  food  or  acrid  fluid-water-brash  or  pyrosis, 
and  pain  or  soreness  at  the  pit  of  the  stomach  during  digestion  are 
also  present.  There  is  drowsiness  after  meals  and  insomnia  at  night. 
Defective  memory,  headache,  diminution  or  absence  of  mental  vigor, 
flashes  of  heat,  followed  by  more  or  less  perspiration,  and  palpitation 
may  be  manifested.  The  tongue  is  usually  broad,  flabby,  and  pale 
and  shows  marks  of  the  teeth.  The  bowels  are  constipated  and  the 
urine  is  scanty,  high-colored,  and  contains  an  excess  of  urates  and 
oxalates;  in  the  nervous  type,  it  is  pale,  of  low  specific  gravity,  and 
contains  phosphates. 

Varieties  of  Dyspepsia. — There  are  many  varieties  of  dyspepsia 
described,  and  the  following  table  (from  Wheeler  and  Jack)  shows 
the  principal  points  of  the  chief  forms.  The  types  sometimes  over- 
lap; hence  the  table  must  be  taken  as  a  guide  only: 


DYSPEPSIA 


241 


Atonic   dyspepsia. 
(Gastric  insuffi- 
ciency) 


Acid  dyspepsia.      1  >t  , 

(Gastric  irritation)     Nervous  dyspepsia 


Immediate  cause . 


Pain,  vomiting,  etc. 


Eructations. 


Examination  of  gastric 
contents. 


Tongue. 


Urine 

Special  points. 


Want  of  functional 
power,  both  as  re- 
gards gastric  secre 
tion  and  move- 
ments. Hence 
often  secondary  to 
constitutional  dis- 
eases. 

Fullness  and  oppres- 
sion in  chest  after 
meals;  vomiting 
absent. 


Eructations  not 

frequent,  but  flat- 
ulence very 
marked.  Often 
some  dilatation 
of  stomach. 

Deficiency  of  HCl. 
Excess  of  lactic 
acid. 

Broad,  flabby,  pa- 
pillae raised,  furred 
at  the  back,  and 
tremulous. 


Normal  or  high- 
colored  from 
urates. 

Most  common 
amongst        young 

women.  Apt  to 
persist. 


Usually       primary.    Mental  strain  from 


but  may  follow 
other  diseases.  De- 
pendent on  errors 
of  diet,  drink,  etc. 


Dull  pain  some 
time  after  food; 
nausea  and  vomit- 
ing. 


Flatulence  common. 


Excess  of  HCl,  and 
sometimes  of  lactic 
and  butyric  acids. 

Broad  also,  but 
usually  coated 

with  a  thick  yel- 
lowish fur.  Saliva 
increased  at  first, 
mouth  afterward 
dry. 

High-colored  de- 
posits, "gravel," 
and  oxalates. 

Most  common 

amongst  middle- 
aged  people  of 
generous  build. 
Paroxysmal  in 

character,  mi- 

graine and  mental 
depression  marked 
during  the  attack. 


worry,  overstudy, 
hysteria,  neuras- 
thenia, etc. 


Often  severe  gas- 
tralgia,  relieved  by 
food;  but  may 
simulate  pain  of 
ulcer.  Vomiting 
not  common. 

Eructations  of  gas 
or  fluid  very 
marked,  and  flatu- 
lence extreme. 
Hiccough  very 
frequent. 

Secretion  of  HCl 
variable;  often  in 
excess,  at  other 
times  deficient. 

Is  usually  clean, 
raw-beef-like  in 
character,  pointed 
tip,  firm,  not 
flabby. 


Pale  deposit  of 
amorphous  phos- 
phates. 

Most  common  in 
neurasthenics,  or 
those  subject  to 
nervous  altera- 
tions. Little  in- 
fluenced by  treat- 
ment, the  predis- 
position remain- 
ing. Insomnia  a 
prominent  symp- 
toin,  and  other 
nervous  disturb- 
ances common. 


Prognosis. — With  the  institution  of  proper  treatment  the  outlook 
is  favorable,  otherwise  the  duration  is  indefinite. 

Treatment. — As  dyspepsia  is  a  symptom,  the  probable  cause 
should  be  sought,  and  if  possible  removed.  The  patient's  coopera- 
tion is  very  desirable;  and  it  should  be  remembered  that  each 
patient  has  his  own  peculiarities.  Regulation  of  the  diet  is  of 
great  importance;  but  the  use  of  rigid  diet  charts  will  often  result 
in  failure.  Saccharine,  starchy,  or  fatty  articles  of  food  should  be 
interdicted.  Mastication  should  be  slow  and  complete  and  only 
16 


242  DYSPEPSIA 

small  quantities  of  food  should  be  taken  at  a  time.  Underdone 
meats,  "Salisbury  steaks,"  eggs,  fish,  oysters,  and  green  vegetables 
with  stale  or  brown  bread  are  advised.  Stimulants  should  not  be 
taken  with  the  meals,  and  only  small  quantities  of  liquids  should 
be  allowed.  Rest  of  a  half  to  an  hour's  duration  after  meals  is  of 
benefit.  General  physical  and  mental  rest  is  indicated  in  the  nervous 
type. 

The  medicinal  treatment  embraces  a  great  ntunber  of  remedies, 
but  care  must  be  taken  not  to  make  a  drug  store  of  the  patient's 
stomach.  As  an  aid  to  digestion,  one  of  the  following  may  be 
prescribed : 

I^.     Pepsini  pur 5j  4  gm. 

Acid,  hydrochlorici  dil f  5iv  15  c.c. 

Glycerini f  3iv  15  c.c. 

Aq.  lauro-cerasi f  §ij  60  c.c. 

M.  S. — One  teaspoonful,  diluted,  with  meals. 

I^.     Papoid  (pur.) gr.  xxx  2.0  gm. 

Sodii  bicarb gr.  Ix  4.0  gm. 

Piilv.  zingib gr.  v  0.3  gm. 

M.     Ft.  capsul.  or  pil.  No.  xx. 
S. — One  at  mealtime  and  bedtime. 

To  stimulate  peristalsis,  nux  vomica,  gentian,  or  cinchona  may 
be  used,  and  for  the  acidity,  alkalies,  particularly  bicarbonate  of 
sodium,  may  be  given.     In  atonic  cases,  Hare  advises : 

I^.     Extracti  nucis  vomicae gr.  iy  0.25  gm. 

Extracti  quassiae gr.  xx  1.30  gm. 

Quininse  siilphatis gr.  xl  2.60  gm. 

'  M.  et  divide  in  pil.  xx. 
S. — One  three  times  a  day  after  meals. 
Or— 

I^.     Extracti  chiratae gr.  xl  2.60  gm. 

Extracti  gentianse gr.  xl  2.60  gm. 

Oleoresinae  capsici Tllv  0.32  gm. 

M.  et  divide  in  pil.  xx. 
S. — One  after  each  meal. 

Purified  animal^charcoal,  gr.'x  to'xx  (0.65  to  1.3  gm.),  or  one  of  the 
carminatives  _^  will  relieve  ?  flatulency.  Pyrosis  may  be  benefited 
by  the  administration  of  bismuth  subnitrate,  gr.  xx  (1.3  gm.),  and 


intsstinal  indigestion  243 

aromatic  powder,  gr.  v  (0.32  ,gm.).  Vomiting  may  be  overcome  by 
the  use  of  sodium  or  strontium  bromide,  gr.  v  (0.3  gm.),  carbolic 
acid;  gr.  3^  to  3^  (o.oii  to  0.016  gm.),  or  chloral  hydrate,  gr.  x  to 
XV  (0.65  to  I  gm.).  Irrigation  of  the  stomach,  or  the  drinking  of 
3^^  to  I  pint  of  hot  water  an  hour  before  meals  is  very  beneficial. 
In  anemic  cases,  iron,  quinine,  strychnine,  and  arsenic  will  be  re- 
quired. For  constipation  Hunyadi  water,  resin  of  podophyllum, 
or  the  following  may  be  used: 

I^.     Sodii  bicarbonatis 5ij  8  gm. 

Tinct.  nucis  vomicae f  3iv  15  c.c. 

Tinct.  capsici f  5  j  4  c.c. 

Tinct.  rhei f  §jss  45  c.c. 

Inf.  gentian.  comp..q.  s.  ad  f^vj  ad  180  c.c. 

M.  S. — Half  tablespoonful  after  meals,  in  water. 

I^.     Fid.  ext.  cascaras  sagradse. .   f  Bj  30  c.c. 

Tinct.  nucis  vomicae f§ss  15  c.c. 

Sjn:.  zingib ,.  f  5  ss  15  c.c. 

Inf.  sarsaparillae q.  s.  ad  f  Biij  ad  90  c.c." 

M.  S. — Teaspoonful  three  times  daily,  diluted. 

DISEASES  OF  THE  INTESTINES 

INTESTINAL  INDIGESTION 

Definition. — Intestinal  indigestion  or  dyspepsia  is  a  functional 
derangement  due  to  defects  in  the  various  intestinal  secretions,  or 
deficient  peristalsis,  or  both,  resulting  in  more  or  less  complete  de- 
composition of  the  chyme;  characterized  by  abdominal  pain  and 
distention,  tympanites  developing  some  hours  after  meals,  emaciation, 
anemia  and  various  nervous  symptoms. 

Causes. — It  may  be  inherited  or  it  may  be  due  to  imperfect  diet, 
over-eating,  irregular  meals,  deficient  exercise,  worry  and  mental 
fatigue,  immoderate  use  of  tobacco,  or  stimulants,  diseases  of  the 
stomach,  intestinal  tract,  liver,  or  pancreas,  or  malaria. 

S3miptoms. — The  affection  may  be  acute  or  chronic. 

The  acute  form  is  usually  the  result  of  an  irritant  in  the  duodenum 
and  is  attended  by  rapidly  developed  pain,  flatulency,  borborygmi, 
slight  fever,  coated  tongue,  loss  of  appetite,  headache,  and  diarrhea. 
In  sudden  attacks,  the  accumulated  gases  often  cause  paroxysms 


244  INTESTINAL    INDIGESTION 

of  colic.  Severe  attacks  are  associated  with  jaundice,  light-colored 
stools,  and  high-colored  urine,  indicating  hepatic  disturbance.  In 
such  cases,  the  onset  is  accompanied  by  malaise,  chilliness,  fever, 
ioo°  to  102°. F.,  increased  pulse,  headache  with  or  without  vomiting, 
coated  tongue,  abdominal  pains  increased  on  pressure,  tympanites, 
cramps  in  the  legs,  and  diarrhea.  The  stools  are  at  first  soft  and 
normal  with  fecal  odor  and  color  becoming  later  frothy,  watery,  of 
a  peculiar  odor,  and  made  up  of  mucus  and  undigested  food.  Their 
reaction  is  alkaline,  and  the  microscope  shows  epithelial,  round,  and 
blood-cells,  Charcot's  crystals,  crystals  of  the  oxalate  of  calcium, 
calcium  phosphate,  etc. 

The  chronic  variety  follows  varying  grades  of  decomposition  in 
the  pasty,  digested  food  after  it  has  left  the  stomach.  It  is  attended 
by  pain,  two  to  four  to  six  hours  after  meals,  with  tenderness  and 
distention  in  the  upper  abdomen,  tympanites,  borborygmi,  dyspnea, 
and  constipation.  Anemia,  emaciation,  functional  derangement  of 
the  liver,  and  marked  nervous  phenomena  develop  as  the  affection 
progresses.  The  skin  is  harsh  and  dry,  and  the  urine  is  high-colored, 
of  increased  specific  gravity,  and  acid  in  reaction,  and  on  cooling 
deposits  lithates,  uric  acid,  and  oxalate  of  lime  crystals. 

Diagnosis. — The  late  appearance  of  the  symptoms  after  ingestion 
of|the  meals  is  the  main  feature  in  distinguishing  intestinal  indiges- 
tion from  gastric  indigestion.  Usually  they  exist  more  or  less 
combined. 

Treatment. — In  the  acute  variety,  opium  should  be  given  and  heat 
applied  to  the  abdomen  to  relieve  the  distress,  and  a  cathartic, 
preferably  calomel,  followed  by  a  saline,  administered  to  expel  the 
irritant. 

I^.   Hydrarg.  chlorid.  mit gr.  J'^  0.02  gm. 

Sodii  bicarb gr.  ij  0.13  gm. 

Pulv.  ipecac gr.  K  O-Oi  g^i- 

Sacch.  lact gr.  iij  0.2    gm. 

M.     Ft.  .narta. 

S. — One  e  ^e:y  two  hours  until  six  have  been  taken. 

After  which  stimulate  the  gastrointestinal  canal  with : 

I^.     Tinct.  nucis  vomicae f5iv  150.0. 

Acid,  hydrochlorici  dil f3iv  15  0.0. 

I     Tinct.  card,  comp iSiv  15  c.c. 

Ess.  pepsin. ......  .q.  s.  ad  f  §iij  ad  90  c.c. 

M.  S. — Teaspoonful  every  three  hours,  diluted. 


INTESTINAL   INDIGESTION  245 

For  the  more  severe  variety  of  intestinal  indigestion  (or  catarrh), 
wash  out  the  large  intestine  with : 

I^.     Magnesii  sulphat 5j  30  gm. 

Glycerini fSJ  30  c.c. 

Aquae  bul f  5iv  120  c.c. 

M.    S. — Slowly   inject   into   bowel   from  a   fountain    syringe. 

Internally  either  of  the  following  excellent  combinations : 

I^.     NaphthaHni gr.  xxx  2.0     gm. 

Bismuth,  salicylat gr.  Ixxx  6.0     gm. 

Acid,  carbolici gr.  iv  0.26  gm. 

Glycerini f 5]  30-0      c.c. 

Aq.  chloroformi fSiij  90.0      c.c. 

M.  S. — Two  teaspoonfuls  every  two  or  three  hours,  diluted. 
Or— 

I^.     Sodii  phosphat 5j  30  gm. 

Acid,  phosph.  dil fSiv  15  c.c. 

Syr.  limonis .  .  f  5j  30  c.c. 

Aq.  chloroformi fSiij  90  c.c. 

Aq.  menth.  pip f  giijss  100  c.c. 

M.  S. — One  tablespoonful  after  meals,  well  diluted. 

Chronic  cases  require  the  administration  of  laxatives  such  as  Bed- 
ford, Friedrichshall,  PuUna,  or  Hunyadi  Janos  waters,  resin  of 
podophyllum,  or  fluidextract  of  cascara  sagrada  and  intestinal 
digestants.  Purified  oxgall,  gr.  j  to  iij  (0.065  ^o  0.2  gm.)  after 
meals,  or  the  following,  may  be  employed: 

I^.     Papoid gr.  j  to  ij  0.065  to  0.13  gm. 

NaphthaHni gr.  j  0.065  gm. 

Ext.  nucis  vomicae gr.  M         0.022  gm. 

M.     Ft.  pil. 

S. — One  such  to  be  taken  every  four  or  six  hours. 

Excellent  results  follow  the  use  of  the  following  pill : 

^.     Sodii  arsenat gr.  Mo  0.003  gm. 

Strychninae  sulphat gr-  H2  0.002  gm. 

Pepsinae  pur gr.  ij  0.13    gm. 

M.  S. — After  each  meal. 

'  The  diet  should  be  restricted  in  amount  and  confined  almost 
entirely  to  articles  which  are  readily  digested  in  the  stomach,  such 
as  beef,  eggs,  and  milk. 


246  INTESTINAL   COLIC 


INTESTINAL   COLIC 

S3mon3mis. — Enteralgia;  tormina;  gripes. 

Definition. — A  spasmodic  contraction  of  the  muscular  layer  of  the 
intestinal  tube;  characterized  by  acute  paroxysmal  pain  near  the 
umbilicus,  relieved  by  pressure,  and  associated  with  feeble  cardiac 
action. 

Causes. — Intestinal  colic  may  be  due  to  constipation,  the  presence 
of  indigestible  food,  or  an  abnormal  quantity  of  bile  in  the  intestinal 
tract,  structural  lesions  of  the  intestinal  wall,  lead-poisoning,  syphilis, 
gout,  rheumatism,  locomotor  ataxia,  malaria,  hysteria,  or  reflex 
causes. 

Symptoms. — Paroxysmal  pain  of  a  tearing,  cutting,  pressing,  twist- 
ing, pinching,  or  bearing-down  character  centering  around  the  um- 
bilicus is  the  most  prominent  symptom.  The  abdomen  is  tense  and 
pressure  upon  it  relieves  the  pain.  In  severe  attacks  the  surface  is 
'cold;  the  features  are  pinched;  the  pulse  is  small  and  hard;  and  there 
may  be  nausea,  vomiting,  and  tenesmus.  Constipation  is  usually 
present.  The  duration  is  from  a  few  minutes  to  several  hours,  often 
with  intermissions.     A  discharge  of  flatus  is  the  usual  termination. 

Diagnosis. — Gastralgia  differs  from  colic,  in  the  pain  being  in  the 
epigastric  region  and  associated  with  disorders  of  digestion. 

In  heptic  colic,  or  the  pain  due  to  the  passage  of  gallstones,  the 
pain  is  in  the  hepatic  region,  radiates  to  the  right  shoulder,  is  attended 
with  soreness  over  the  gall-bladder,  and  retching  and  vomiting, 
followed  by  jaundice  and  the  presence  of  bile  in  the  urine. 

In  nephritic  colic^  the  pain  follows  the  course  of  one  or  both  ureters, 
shooting  to  loins  and  thigh,  with  retraction  of  the  testicle  of  the  af- 
fected side,  strangury,  and  bloody  urine. 

In  uterine  colic,  the  pain  is  in  the  pelvis,  and  associated  with  men- 
strual disorders,  in  fact,  a  dysmenorrhea. 

In  ovarian  colic  or  neuralgia,  there  is  pain  on  pressure  over  the 
ovaries,  with  hysterical  phenomena. 

Inflammatory  disorders  of  the  abdomen  differ  from  colic  by  the  pres- 
ence of  fever  and  tenderness  on  pressure. 

Lead  colic  is  always  preceded  by  symptoms  of  lead-poisoning: 
slate-colored  skin,  dark  gums  showing  a  blue  line,  heavy  breath,* 
with  sweetish  mfetallie  taste,:  obstinate  constipation,  impaired  appe- 
tite, slow  pulse,  and  contracted  abdominal  walls. 


CONSTIPATION  247 

Appendicitis  may  be  distinguished  by  the  locaUzed  pain  and 
tenderness  in  the  right  iliac  fossa,  induration,  andjrigidity  of  the 
right  rectus  abdominis  muscle. 

Prognosis. — Favorable. 

Treatment. — The  pain  should  be  relieved  by  turpentine  stupes  over 
the  abdomen,  carminatives,  and  the  hypodermic  injection  of  mor- 
phine sulphate,  gr.  %  to  }4  (o.oii  to  0.022  gm.).  '  In  all  cases,  blue 
mass,  gr.  v  to  x  (0.3  to  0.6  gm.),  or  calomel,  gr.  >^  (0.03  gm.),  every 
half  hour  until  4  or  5  grains  have  been  taken,  should  be  administered 
and  followed  by  a  saline  cathartic.  In  the  interval,  the  cause  should 
be  ascertained  and  removed. 

In  lead  colic,  morphine,  castor  oil,  or  sulphate  of  magnesium 
potassium  iodide,  syrup  of  hydriodic  acid,  and  olive  oil  are  indicated. 

CONSTIPATION 

Synonjmis. — Costiveness;  intestinal  torpor. 

Definition. — A  functional  inactivity  of  the  intestinal  canal,  either 
due  to  atony  of  the  muscular  coat,  causing  lessened  peristalsis,  or 
to  deficiency  of  intestinal  and  biliary  secretion;  characterized  by  a 
change  in  the  character,  frequency,  and  quantity  of  the  stools. 

Varieties. — There  are,  thus,  three  types  of  constipation:  (i) 
Insufficient  frequency  of  defecation;  (2)  insufficient  quantity;  and 
(3)  defecation  of  abnormally  dry  and  hard  masses. 

Causes. — Diseases  of  the  digestive  tract,  fevers,  diseases  that 
lessen  intestinal  secretions,  affections  that  diminish  peristalsis,  seden- 
tary habits,  neglect,  painful  defecation,  improper  food,  change  of 
diet  or  habits,  malaria,  lead-poisoning,  atony  of  the  intestinal  and 
abdominal  walls,  strictures,  displaced  organs,  and  foreign  bodies  are 
the  common  causes. 

S5miptoms. — One  stool  in  twenty-four  hours  may  be  taken  as  an 
indication  of  the  normal  state  as  regards  the  intestinal  tract;  less  than 
this  constitutes  constipation,  although  it  may  be  unattended  with 
any  discomfort,  for  a  considerable  period.  The  change  in  number, 
quantity,'  and  consistency  gives  rise  eventually  to  straining,  dis- 
tress, tenesmus,  and  irritation  of  the  rectum.  These  are  followed  by 
dyspeptic  symptoms,  anorexia,  headache,  mental  torpor,  vertigo, 
palpitation,  and  often  abdominal  distention. 

Prognosis. — The  outlook  is  favorable  but  the  course  is  likely  to 
be  indefinite.  Hemorrhoids,  varicocele,  impaction,  anal  fissure, 
ulceration,  and  similar  conditions  may  occur  as  sequels. 


248  "        CONSTIPATION 

Treatment. — In  all  cases  a  careful  examination  should  be  made  to 
ascertain  the  cause,  which  should  be  promptly  removed.  A  large 
portion  of  the  treatment  in  ordinary  cases  rests  with  the  patient. 

1.  The  patient  must  have  a  regular  hour  each  day  for  going  to 
stool,  and  must  remain  a  sufficient  time  to  permit  a  thorough  evacua- 
tion of  the  bowels,  until  habit  of  daily  stools  is  formed,  taking  (if 
necessary)  a  warm  water  injection. 

2.  The  diet  must  be  carefully  regulated,  as  concentrated  foods 
increase  the  costive  habit,  so  that  those  predisposed  should  eat 
bulky  foods,  much  vegetables  and  fruits.  Bran  bread,  gluten  bread, 
water-drinking,  cornmeal,  and  oatmeal  should  be  advised. 

3.  Purgative  mineral  waters,  such  as  Saratoga,  Bedford,  Apenta, 
Carlsbad,  Friedrichshall,  and  Hunyadi  Janos  should  be  cautiously 
employed.  Purgation  should  be  avoided  if  possible;  a  mild  laxative 
may  be  used  frequently,  even  habitually  if  necessary.  An  old  favor- 
ite is  the  following  excellent  combination: 

I^.     Aloin gr.  M  0.016  gm. 

Strychnine  sulphatis gr.  Ko  o.ooi  gm. 

Extr.  belladonnae gr.  He  0.004  gm. 

Extr.  cascarae  sagradse gr.  ss  0.032  gm. 

M.  S. — One  such  pill  t.  i.  d. 

Epsom  salt  or  Rochelle  salt  is  a  very  efficient  drug  in  this  condition. 
Aloin,  gr.  ^  to  3^  (0.008  to  0.016  gm.),  after  meals,  or  glycerin  in 
enema  or  suppository  may  also  be  employed  to  combat  the  constipa- 
tion. The  tone  of  the  intestinal  wall  may  be  restored  by  electricity 
or  kneading  of  the  abdominal  walls,  systematic  exercise,  cold  bathing, 
and  massage. 

4.  The  administration  of  one  of  the  following  formulas: 

I^.       Ext.  nucis  vomicae gr.  34  o .  016  gm. 

Ext.  belladonnae  (alco.)  .  .  .  gr.  34  0.016  gm. 

Ext.  aloes gr.  ss  o .  032  gm. 

Pulv.  rhei gr.  j  o .  065  gm. 

Olei  cajuputi ITlj  o .  06    c.c. 

M.  S. — In  pill,  at  bedtime;  and  after  a  week,  every  second 
or  third  night. 

I^.     Resinae  podophyl., 
Ext.  physostig., 
Ext.  belladonnae  (alco.), 

Aloini aa  gr.  34         aa     0.016  gm. 

M.  S. — In  pill,  every  night,  or  second  or  third  night. 


DIARRHEA  249 

I^.     Fid.  ext.  cascarae  sagradae  .    Tllxx  i .  3  c.c. 

Glycerini Tllxx  i .  3  c.c. 

Syr.  sarsaparillae TTtxx  i .  3  c.c. 

M.   S. — To  be  taken  one  hour  after  meals,   or  once  a  day, 
as  indicated. 

Treatment  of  Constipation  of  Infants.— T>Tmkmg  of  a  little  water 
or  barley  water,  or  oatmeal  water,  will  often  overcome  the  difficulty. 
Small  suppositories  of  glycerin  or  soap  may  be  used  or  an  injection 
of  cold  water  be  tried,  and,  if  necessary,  repeated.  For  older  chil- 
dren, castor  oil  or  effervescent  magnesium  sulphate  will  be  found 
suitable;  but  fruit  should  be  tried  first.  Drugs  should  not  be  used 
if  any  other  method  will  suffice. 

DIARRHEA 

Synon5nais. — Enterorrhea;  alvine  flux;  purging. 

Definition. — Frequent  loose  alvine  evacuations,  without  tenesmus; 
due  to  functional  or  organic  derangement  of  the  small  intestines, 
produced  by  causes  acting  either  locally  or  constitutionally. 

Causes. — Among  the  local  causes  may  be  mentioned  indigestion, 
indigestible  food,  impure  food  and  water,  irritating  matters  or  secre- 
tions poured  into  the  bowels,  intestinal  inflammation,  and  entozoa. 
The  general  causes  include  atmospheric  changes,  sudden  mental 
shock,  purgatives,  certain  infectious  fevers,  and  cachectic  conditions 
such  as  attend  tuberculosis,  pyemia,  Bright's  disease,  cancer, 
diabetes,  etc. 

Symptoms. — Diarrhea  may  be  acute  or  chronic  and  is  manifested 
chiefly  by  an  alteration  in  the  number  and  character  of  the  stools. 
Mucous  stools  are  those  in  which  there  are  great  quantities  of  mucus, 
indicating  inflammation  of  the  lower  bowel.  Lienteric  stools  contain 
much  undigested  food  and  point  to  inflammation  of  the  stomach 
and  upper  bowel.  Watery  or  serous  stools  occur  in  nervous  and 
colliquative  diarrheas,  enteritis,  cholera,  and  similar  affections. 
Green  stools  may  be  due  to  an  excess  of  bile,  bacterial  growth,  or 
marked  alkalinity  of  the  digestive  tract.  Fatty  stools  are  produced 
by  the  ingestion  of  large  quantities  of  fatty  foods,  pancreatic  dis- 
eases, and  the  absence  of  bile.  Purulent  stools  arise  from  ulceration 
along  the  intestinal  canal  or  the  rupture  of  adjacent  abscesses  into 
the  bowel.  Black  stools  may  be  due  to  the  presence  of  blood  from 
hemorrhages  high  up  in  digestive  tract,  bismuth,  charcoal,  tannate 


250  DIARRHEA 

of  iron,  etc.  Red  stools  may  result  from  the  presence  of  fresh  blood 
or  the  administration  of  diarrhea  mixtures  containing  hematoxylon. 
Bloody  stools  or  melena  follow  hemorrhage  from  any  portion  of  the 
digestive  tract  and  result  from  inflammation,  ulceration,  traumatism, 
infectious  fevers,  chronic  heart,  liver,  or  kidney  disease,  infarction, 
hemorrhoids,  anal  fissure  and  fistula,  rupture  of  an  aneurysm, 
scurvy,  purpura,  and  vicarious  menstruation. 

Acute  diarrhea  presents  itself  in  several  forms.  In  the  feculent 
form  which  results  from  indiscretions  in  diet,  intestinal  parasites,  and 
indigestion,  the  patient  experiences  within  a  few  hours  after  meals 
colicky  pains,  nausea,  flatulency,  and  a  desire  for  stool.  The  tongue 
may  be  coated.  Purging  relieves  the  pain.  The  stools  are  composed 
of  a  brown  fluid  and  feces,  and  are  very  offensive.  Their  color 
becomes  lighter  after  four  or  five  evacuations.  The  duration  is 
seldom  more  than  two  or  three  days.  In  the  lienteric  variety,  the 
food  passes  through  unaltered  or  very  slightly  digested.  The  stools 
are  frequent  and  in  addition  to  the  undigested  food,  there  is  bile, 
mucus,  and  serum.  Emaciation  is  common.  In  the  bilious  form, 
which  is  due  to  excess  of  bile,  griping  pains  in  the  abdomen  and  scald- 
ing sensations  at  the  anus  are  present,  and  the  stools  are  green  or 
yellow. 

Chronic  diarrhea  results  from  the  persistence  of  acute  diarrhea 
or  constitutional  affections.  The  stools  continue  frequent,  but  are 
paler  in  color.  Emaciation,  anemia,  dyspepsia,  etc.,  accompany 
this  affection. 

Prognosis. — As  diarrhea  is  only  a  symptom  its  prognosis  depends 
upon  the  underlying  condition.  In  the  feculent  and  bilious  forms 
it  is  favorable,  but  in  the  lienteric  and  chronic  forms,  when  emaciation 
begins,  it  assumes  an  unfavorable  character. 

Treatment. — Acute  Diarrhea. — If  the  tongue  is  heavily  coated, 
the  breath  fetid,  and  the  stools  not  excessive  in  number,  it  is  well  to 
clear  the  intestinal  canal  with  a  laxative  such  as  castor  oil  or  a  saline. 
For  children  between  one  and  two  years  of  age : 

I^.     Pulv.  ipecac gr.  ss  o .  032  gm. 

Pulv.  rhei gr.  J^  to  3^  o .  016  to  0 .  022  gm. 

Sodii  bicarb gr.  ss  to  ij       o .  032  to  0.13    gm. 

M.  S. — Every  four  hours  until  the  character  of  the  stools  changes. 

As  a  rule,  however,  the  stools  have  become  so  frequent  when  advice 
is  sought  that  the  time  for  laxatives  has  passed,  and  some  one  of  the 
following  combinations  is  indicated: 


DIARRHEA  2$! 

^.     Salol gr,  XX  to  xxx  i .  3  to  2  .  o  gm. 

Bismuth  subnitrat 5j  4-0  gm. 

Sacch.  lac 3j  4.0  gm. 

M.     Ft.  chart.  No.  x. 

5. — One   every   two   or   three  ^hours,    reducing   the    dose    for 
children. 


Or- 


I^.     Bismuthi  salicylat gr.  xxx  2.0      gm. 

Morphinse  sulphat gr.  o. 065  gm. 

M.     Ft.  chart.  No.  vj. 

S. — One  every  three  hours. 

Or  the  following  modification  of  Squibb 's  "diarrhea  mixture:" 

I^.     Tinct.  opii  deodorat f  3iv  15  c.c. 

Tinct.  camphorse f5iv  15  c.c. 

Tinct.  capsici f  5ij  8  c.c. 

Chloroformi f  3jss  6  c.c. 

Spt.  vini  galHci f  5j  30  c.c. 

Vini  pepsini q.  s.  ad  f  5iij  ad     90  c.c. 

M.  S. — One  teaspoonful,  p.  r.  n. 

Or  the  following  : 

I^.     Tinct.  opii  deodorat f5iv  15  c.c. 

Spt.    chloroformi fSij  8  c.c. 

Acid,  sulphuric,  dil f  §  j  30  c.c. 

Vini  pepsini q.  s.  ad  f  Biij  ad       90  c.c. 

M.  S. — One  teaspoonful  in  water  after  each  stool. 

For  the  bilious  form : 

I^.     Hydrarg.  chlorid.  mitis. ...   gr.  3^  0.008  gm. 

Sodii  bicarb gr.  ij  0.13    gm. 

Pulv.  opii gr.  M  0.016  gm. 

M.   S. — Every  two   or  three  hours  until  eight  powders   are 
used,  followed  by  large  doses  of  bismuth  and  pepsin. 

In  all  acute  forms,  restricted  and  regulated  diet  is  imperative, 
pure  milk  with  lime-water  being  the  most  suitable. 

In  adults,  an  opium  suppository  often  checks  a  flux  that  is 
uninfluenced  by  opium  internally. 

Irrigation  of  the  eplpn.  with  a  warm  salt  solution  is  often  beneficial. 


252  CATARRHAL   ENTERITIS 

Chronic  Diarrhea. — Bismuth,  gr.  xxx  to  xl  (2  to  2.6  gm.),  in  milk 
every  four  hours;  Hope's  camphor  mixture,  f Bj  (30  c.c),  every  four 
hours;  or  copper  sulphate,  gr.  1^2  (o-oo5  g^i.),  extract  of  opium,  gr. 
^2  (0-005  gm-)>  every  four  hours;  or  silver  nitrate,  gr.  %  (0.0 1 
gm.),  extract  of  opium,  gr.  1^  (o.oii  gm.),  every  five  hours;  may  all 
be  used  with  more  or  less  success;  when  dry  tongue  and  great 
flatulency  are  present,  use: 

I^.      01.  terebinthinse f  5  j  4  c-c 

01.  amygdal.  express f  §ss  15  c.c. 

Tinct.  opii f  5ij  8  c.c. 

Mucil.  acaciae fSiv  15  c.c. 

Aq.  lauro-cerasi f§ss  15  c.c. 

M.   S. — One  teaspoonful  every  three  or  four  hours,   diluted. 

The  diet  should  be  nutritious  in  character,  and  stimulants  in 
moderation  are  indicated.  Activity  of  the  skin  and  kidneys  should 
be  encouraged. 

All  varieties  of  intestinal  catarrh  or  diarrhea  are  benefited  by  a 
few  days'  rest  in  bed  and  daily  hot  baths. 

CATARRHAL  ENTERITIS 

Synonj^ms. — Intestinal  catarrh;  acute  diarrhea;  ileocolitis;  inflam- 
mation of  the  bowels. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  small  intestines;  characterized  by  fever,  pain, 
tenderness,  and  looseness  of  the  bowels.  When  the  catarrh  is  limited 
to  the  duodenum  it  is  termed  duodenitis,  and  is  attended  by  slight 
jaundice. 

Causes. — In  some  cases,  a  specific  virus  seems  to  be  the  etiological 
factor.  Ptomaine  poisoning,  such  as  follows  the  ingestion  of  decom- 
posed food  and  milk,  improper  and  indigestible  food,  over-eating,  and 
excessive  drinking,  summer  season,  exposure  to  cold  and  wet  while 
perspiring,  irritants  such  as  foreign  bodies  in  the  intestinal  tract, 
childhood,  imperfect  hygiene,  and  inorganic  poisons  may  be  men- 
tioned as  the  most  common  causes. 

Pathological  Anatomy. — There  first  ensues  hyperemia  of  the 
mucous  membrane  and  intestinal  glands,  manifested  by  redness, 
swelling,  and  edema;  this  is  followed  by  increased  secretion,  and 
anl^overgrowth  and  desquamation  of  the  epithelium,  together  with 


CATARRHAL    ENTERITIS  253 

a  copious  generation  of  young  cells.  As  a  result  of  the  hyperemia, 
rupture  of  the  capillaries  and  extravasation  of  blood  often  occur. 

The  swollen  glands  show  a  strong  tendency  to  ulcerate.  This 
catarrhal  process  may  involve  the  entire  tube  or  be  limited  to  por- 
tions of  it.  If  the  catarrhal  changes  extend  to  the  ileum,  the  solitary 
and  Peyer's  glands  show  swellings  that  might  be  mistaken  for  the 
changes  of  typhoid  fever. 

Symptoms. — The  acute  form  begins  with  languor,  chilliness,  fever 
102°  to  io3°F.,  anorexia,  colicky  pains,  and  localized  abdominal 
tenderness.  Nausea  and  vomiting  often  occur.  The  bowels  are 
at  first  constipated,  but  later  diarrhea  supervenes.  The  stools  at 
first  have  ordinary  fecal  contents  and  are  very  offensive,  later  they 
are  less  offensive  and  contain  but  little  fecal  matter;  are  yellow  or 
greenish -yellow  in  color,  and  mixed  with  undigested  food.  When 
very  numerous  they  become  thin  and  watery,  constituting  the  so- 
called  '^rice-water"  discharges.  A  peculiar  abdominal  eruption  has 
been  observed  in  severe  cases;  it  occurs  as  isolated  dark, red  spots, 
larger  than  those  of  typhoid  fever,  disappearing  on  pressure  and  with 
the  decline  of  the  fever,  each  lesion  lasting  about  twenty-four  hours. 

In  the  chronic  form,  in  addition  to  the  diarrhea,  emaciation  and 
anemia  are  present.  The  stools  are  thin,  watery,  and  numerous. 
The  presence  of  undigested  food  in  the  evacuations  indicates  inflam- 
mation of  the  small  intestine,  while  the  presence  of  considerable 
mucus  points  to  involvement  of  the  large  intestines. 

Diagnosis. — Colic  resembles  enteritis  only  in  the  character  of  the 
pain,  and  lacks  abdominal  tenderness,  diarrhea,  and  fever. 

Typhoid  fever  is  distinguished  by  its  prodromes,  temperature 
record,  eruption,  enlarged  spleen,  character  of  the  stools,  and  the 
Widal  reaction. 

Dysentery  is  characterized  by  small,  mucous  blood-stained 
discharges,  and  marked  tenesmus. 

Peritonitis  may  be  differentiated  by  its  intense  pain  and  tender- 
ness, tympany,  marked  constitutional  reaction,  decubitus,  and 
constipation. 

Cholera  may  resemble  enteritis  when  the  attack  is  mild,  but  a  bac- 
teriological examination  of  the  stools  will  aid  in  making  the  diagnosis. 

Prognosis. — The  prognosis  is  favorable  when  the  treatment  is 
prompt  and  appropriate.  Mild  cases  last  for  four  or  five  days, 
severe  cases  may  continue  for  one  or  two  weeks.  In  chronic  enteritis, 
the  diarrhea  may  persist  indefinitely. 


254  CATARRHAL  ENTERITIS 

Treatment. — The  patient  should  be  placed  in  bed  and  the  diet 
restricted  to  such  articles  as  milk,  and  lime-water,  or  mutton  or 
chicken  broths  to  which  well-boiled  rice  has  been  added.  In  most 
cases  it  is  well  to  begin  the  treatment  by  the  administration  of  some 
mild  laxative  such  as  calomel,  magnesia,  or  Epsom  salt  to  relieve 
the  intestinal  tract  of  irritants.  For  adults,  the  best  remedy  is 
opium.     The  following  formulas  may  be  employed: 

I^.     Ext.  opii gr.  M  to  3^  0.016  to  0.032  gm. 

Camphorae  pulv gr.  iij  0.2  gm. 

M.  S. — In  pill,  every  three  hours. 

Or— 

I^.     Tinct.  opii  deodorat lUx  o .  6  c.c. 

Liq.  potassii  citrat f  5ij  8.0  c.c. 

M.  S. — Every  hour  until  opium  effect  is  manifested. 

The  strength  and  the  frequency  of  administration  of  either  of 
these  formulas  must  be  governed  by  the  severity  of  the  attack. 

Salol,  gr.  j  to  iij  (0.065  to  0.2  gm.),  alone  or  combined  with  bismuth 
salicylate,  gr.  x  to  xv  (0.6  to  i  gm.),  every  three  hours  may  also  be 
used. 

If  vomiting  is  annoying,  all  other  treatment  must  be  discontinued 
until  it  has  been  controlled,  the  following  being  usually  efficient: 

I^.     Hydrarg.  chlorid.  mit gr.  )^  o .  008  gm. 

Sodii  bicarbonat gr.  ij  o.  13    gm. 

Sacch.  lac gr.  ij  0.13    gm. 

M.  S. — Every  hour  or  two,  dry,  on  tongue. 

For   children: 

I^.     Tinct.  opii  deodorat TTlj  o .  06  c.c. 

Bismuth,  subnitrat gr.  v  0.32  c.c. 

Mist,  cretse f5j  4-o    c.c. 

M.  S. — Every  two  hours,  for  a  child  of  one  year. 

If  the  disease  shows  the  least  tendency  to  Hnger,  the  acid  treat- 
ment should  be  substituted,  one  of  the  best  formulas  being  ''Hope's 
Camphor  Mixture."  The  following,  which  has  been  used  with  much 
success  in  the  insane  wards  of  the  Philadelphia  Hospital,  is  generally 
satisfactory : 


CROUPOUS  ENTERITIS  255 

I^.     Spt.   camphorae fSJ  30  c.c. 

Acid,  sulphurici  dil f  5jss  45  c.c. 

Tinct.  opii  deodorat fgj  30  c.c. 

Tinct.  capsici f§ss  15  c.c. 

Spt.    chloroformi fgss  15  c.c. 

Spt.  vini  gallici...  .q.  s.  ad  fBvj  ad        180  c.c. 

M.  S. — One  to  two  teaspoonfuls,  well  diluted,  every  three  or 
four  hours. 

In  chronic  cases,  every  attention  must  be  given  to  the  diet,  hygiene, 
clothing,  etc.  Irrigation  of  the  colon  with  silver  nitrate  solution 
(20  gr.  to  the  pint)  may  be  necessary.  Mineral  astringents  and 
intestinal  antiseptics  are  of  great  value. 

Locally. — Poultices,  warm  fomentations,  such  as  turpentine  stupe, 
belladonna  ointment,  or  camphorated  oil,  are  agreeable. 

CROUPOUS  ENTERITIS 

Synonym. — Membranous  enteritis;  pseudomembranous  enteritis; 
diphtheritic  enteritis. 

Definition. — A  croupous  inflammation  of  the  mucous  membrane 
of  the  small  intestines;  characterized  by  tenderness,  paroxysmal 
pain,  moderate  fever,  and  the  formation  and  discharge  at  stool  of 
membranous  shreds  or  casts. 

Causes. — Adult  life,  female  sex,  neurotic  temperament,  hysteria, 
and  hypochondriasis  are  the  principal  etiological  factors.  A  true 
croupous  enteritis  may  occur  in  poisoning  by  inorganic  substances, 
in  the  acute  infectious  diseases,  and  in  the  several  cachexias. 

Pathological  Anatomy. — A  subacute  inflammation  of  the  small 
intestine,  during  which  the  mucous  membrane  to  a  variable  extent 
and  depth  becomes  covered  with  a  whitish  or  grayish-white,  firmly 
adherent,  membranous  deposit,  cemented  together  by  a  coagulable 
exudation,  and  prolonged  by  rootlets  from  the  under  surface  into 
the  intestinal  follicles. 

Symptoms. — The  affection  is  manifested  by  paroxysms,  each 
of  which  is  preceded  by  various  neurotic  symptoms.  The  attack 
begins  with  feverishness,  sense  of  soreness  and  distention  of  the  abdo- 
men, colicky  pains  of  a  spasmodic  character  centering  around  the 
umbiHcus,  and  abdominal  tenderness,  which  phenomena  continue 
for  one  or  two  days.  Diarrhea,  pain,  and  tenesmus  with  the  pres- 
ence of  mucus,  shreds  of  membrane  or  cylindrical  casts  of  the  bowel, 


256  CHOLERA   MOEiBUS 

and  sometimes  blood  in  the  stools,  then  become  manifest.  Relief 
follows  the  discharge  of  the  casts  although  the  generalized  abdominal 
soreness  may  persist  for  a  few  days. 

Diagnosis. — Peritonitis  and  dysentery  may  resemble  it  in  the 
early  stage,  but  the  mucous  casts  and  membranous  shreds  which  are 
passed  within  the  first  forty-eight  hours,  as  a  rule,  will  serve  to  make 
the  diagnosis. 

Prognosis. — Life  is  never  threatened,  but  the  disease  is  very  obsti- 
nate to  treatment.  The  paroxysms  occur  at  intervals  of  a  week  or 
two,  but  may  be  postponed  for  several  months. 

Treatment. — The  underlying  neurotic  condition  should  receive 
the  most  careful  attention.  In  addition,  the  diet  should  be  restricted 
so  as  to  reduce  the  liquids  to  a  minimum.  The  pain,  which  is  some- 
times excruciating,  may  require  some  preparation  of  opium,  prefer- 
ably morphine,  hypodermically.  The  administration  of  an  emulsion 
of  castor  oil  and  turpentine  will  aid  in  the  expulsion  of  the  cast 
and  overcome  any  tendency  toward  constipation.  Da  Costa  recom- 
mends some  preparation  of  liquid  tar  for  its  alterative  effect  on  the 
mucous  membrane.  Alteratives  such  as  cod-liver  oil.  Fowler's  solu- 
tion of  the  arsenite  of  potassium,  TTtj  to  iij  (0.06  to  0.12  c.c),  or 
bichloride  of  mercury,  gr.  }^  (o.ooi  gm.),  may  serve  to  prevent  return 
of  the  paroxysms. 

CHOLERA  MORBUS 

Synonjnns. — Sporadic  cholera;  English  cholera;  cholera  nostras; 
bilious  cholera. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  of  sudden  onset;  charac- 
terized by  violent  abdominal  pains,  incessant  vomiting  and  purging, 
cold  surface,  rapid,  feeble  pulse,  spasmodic  contractions  of  the 
muscles  of  the  abdomen  and  extremities,  and  prostration. 

Causes. — Summer  and  early  autumn  season,  sudden  changes  in 
the  temperature,  and  the  presence  of  irritants  in  the  digestive  tract 
such  as  result  from  the  decomposition  of  food,  and  unripe  fruit  and 
vegetables  seem  to  be  the  most  important  factors  in  its  production. 
A  special  microorganism  resembling  the  comma  bacillus  is  often 
present  in  the  stools ;  but  its  causal  relation  has  not  been  established. 

Pathological  Anatomy. — Except  in  cases  in  which  death  has 
occurred  within  a  few  hours,  the  gastrointestinal  mucous  membrane 


CHOLERA  MORBUS  257 

is  congested  and  denuded  of  epithelium,  and  the  solitary  glands  and 
Peyer's  patches  are  swollen  and  prominent.  The  blood  is  thick 
and  dark  in  color;  the  kidneys  are  enlarged  and  congested;  and  in 
prolonged  cases  granular  changes  appear  in  the  muscles. 

Symptoms. — The  onset  is  sudden  and  violent  and  often  occurs 
after  midnight,  being  manifested  by  chilliness,  intense  nausea, 
vomiting,  and  purging  accompanied  by  distressing  burning  or  tear- 
ing abdominal  pains  or  colic.  The  vomited  matter  at  first  consists 
of  the  ordinary  contents  of  the  stomach,  but  is  soon  replaced  by 
bilious  material  and  later,  almost  pure  water.  The  stools  are  fre- 
quent and  often  continuous.  At  first,  ordinary  feces  are  discharged, 
then  liquid  whitish  or  greenish  stools,  and  later  "rice-water"  stools 
resembling  those  of  Asiatic  cholera.  The  surface  of  the  body  is 
cold  and  covered  with  clammy  sweat,  and  in  severe  cases,  intense 
muscular  cramps  are  present.  The  pulse  is  small  and  feeble  and 
there  is  intense  thirst.  Collapse  may  occur.  The  patient  becomes 
rapidly  weak  and  emaciated,  the  body  appearing  to  shrink  as  in 
Asiatic  cholera. 

Diagnosis. — Asiatic  cholera  may  resemble  cholera  morbus,  but 
the  history  and  the  presence  of  the  comma  bacillus  of  Koch  in  the 
stools  of  the  former  will  serve  to  make  the  diagnosis. 

Irritant  poisons,  such  as  tartar  emetic  and  elaterium,  produce 
symptoms  that  may  be  mistaken  for  cholera  morbus  and  can  only 
be  distinguished  by  the  history  and  the  detection  of  the  cause. 

Prognosis. — The  outlook  is  favorable  in  most  cases;  the  mor- 
tality in  all  grades  being  about  5  per  cent.  Either  extreme  of  life 
has  an  unfavorable  influence.  Mild  cases  may  last  only  one  or  two 
days,  but  in  the  more  severe  cases  the  affection  may  persist  for  one 
or  more  weeks  and  be  followed  by  a  tedious  convalescence. 

Treatment. — In  all  cases,  regardless  of  the  cause,  a  hypodermic 
injection  of  morphine  sulphate,  gr.  3^  to  ^^  (0.008  to  0.022  gm.), 
and  atropine  sulphate,  3^20  (0.00054  gm.),  should  be  administered, 
to  be  repeated  in  a  half  hour  if  necessary.  Liquid  preparations  of 
opium  by  the  mouth  or  rectum  may  be  occasionally  necessary 
instead.  The  various  cholera  mixtures  (see  page  no)  are  useful;  so, 
too,  is  Hope's  camphor  mixture.  Chlorodyne  should  not  be  used  as 
its  very  variable  strength  and  uncertain  composition  make  it  more 
dangerous  than  useful.  The  depression  may  be  relieved  by  small 
doses  of  brandy  or  dry  champagne.  Small  pellets  of  ice  will  over- 
come the  intense  thirst  to  some  extent,  but  liquids  are  contra- 
17 


258  •      ENTEROCOLITIS 

indicated.     If  the   vomiting   and  purging  continue,   the  following 
may  be  made  use  of: 

I^.     Bismuth,  subnitrat gr.  xx  1.3    gm. 

Acid  carbol gr.  K  o  •  01  gm.  1 

Glycerini Illxx  i .  3    c.c. 

Aquae f5iv  150    c.c. 

M.  S. — Every  hour,  in  water. 

If  the  vomiting  is  so  severe  that  no  opportunity  occurs  for  the 
medicament  to  come  in  contact  with  the  gastric  mucous  membrane, 
an  enema  of  chloral,  gr.  x  to  xv  (0.6  to  i  gm.),  in  some  demulcent 
with  deodorized  tincture  of  opium,  Tllx  to  xx  (0.6  to  1.2  c.c),  acts 
often  like  magic  in  quieting  the  distress  of  the  tortured  patient. 

For  the  muscular  cramps  DaCosta  employs: 

I^.     Chloral 5iv  I5  g^- 

Petrolat Bj  32  gm. 

M.  S. — -To  be  rubbed  over  the  affected  muscles. 

Bartholow  suggests: 

I^.      Chloral Siij               •  12.0    gm. 

Morphinse  sulphat gr.  iv  0.26  gm. 

Aquae f 5j  30.0    c.c. 

M.    S. — Twenty   minims,    h^^podermically,  repeated   p.    r.    n. 

Locally,  mustard  poultices,  turpentine  stupes,  and  hot  water- 
bottles  to  the  abdomen  will  be  of  benefit. 

The  after-treatment  will  consist  largely  in  regulation  of  the  diet 
and  a  course  of  tonics. 

ENTEROCOLITIS 

Synonjons. — Inflammatory  diarrhea;  ulcerative  enterocoHtis. 

Definition. — A  catarrhal  inflammation  of  the  lower  portion  of  the 
small  intestines — ^ileum — and  the  upper  portion  of  the  large  intes- 
tines, with  a  great  tendency  to  ulceration  of  the  intestinal  glands  if 
the  catarrh  becomes  chronic. 

Causes. — The  affection  is  most  common  in  childhood,  particu- 
larly in  the  second  summer.  Improper  and  indigestible  food, 
artificial  feeding,  summer  season,  impure  air,  uncleanHness,  and 
exposure,  are  important  etiological  factors.  It  may  follow  any 
of  the  infectious  fevers  and  disorders  of  the  intestinal  tract  such  as 
diarrhea  and  cholera  infantum.  The  Bacillus  dysentericB  of  Shiga 
is  often  present  in  the  evacuations, 


ENTEROCOLITIS  259 

Pathological  Anatomy. — The  disease  may  be  acute  or  chronic.  In 
the  acute  variety,  hyperemia,  swelling,  edema,  and  softening  of  the 
mucous  membrane  of  the  ileum  and  upper  part  of  the  colon  are 
present.  The  intestinal  follicles  are  considerably  hyperplastic, 
their  excretory  ducts  being  enlarged  and  tumid,  and  readily  dis- 
tinguished as  grayish  or  blackish  points  in  the  center  of  the  glands. 
Peyer's  patches  present  the  same  changes  and  a  similar  appearance, 
often  seemingly  ulcerated,  but  true  ulceration  is  absent.  In  severe 
cases  there  may  be  a  pseudomembranous  formation. 

In  the  chronic  variety,  the  thickening  and  infiltration  involves  the 
submucous  and  muscular  coats  producing  induration  and  rigidity 
of  the  intestinal  walls.  Ulceration  occurs  and  extends  through  the 
entire  thickness  of  the  membrane.  "These  ulcers,  when  isolated, 
are  from  i  to  i}i  lines  in  diameter,  oval  or  circular  in  shape,  and 
either  have  sharp-cut  edges,  as  though  the  piece  of  mucous  membrane 
had  been  cut  out  with  a  punch,  or  the  mucous  membrane  bounding 
them  is  undermined."  The  small  ulcers  often  coalesce,  so  that 
large,  irregular  ulcerated  patches  of  a  grayish  white  color  are  formed, 
having  for  their  base  the  submucous  or  muscular  coats.  The  mesen- 
teric glands  are  enlarged,  but  seldom,  if  ever,  undergo  idceration. 

Symptoms. — The  acute  form  may  develop  slowly  with  restlessness 
or  fretfulness,  or  suddenly  with  feverishness,  loss  of  appetite,  thirst, 
nausea,  vomiting,  abdominal  pain,  and  diarrhea.  The  abdomen 
soon  becomes  enlarged  and  tender.  The  stools  are  characteristic, 
being  small,  semifluid,  heterogeneous,  greenish,  acid,  and  mixed 
with  yellowish  particles  of  ordinary  feces  and  undigested  casein 
which  give  to  the  evacuation  the  appearance  of  chopped  spinach. 
They  vary  in  number  from  fifteen  to  thirty  in  twenty-four  hours. 
The  temperature  is  irregular  (102°  to  io4°F.)  and  the  pulse-rate  is 
increased.     Emaciation  is  rapid  and  pronounced. 

The  chronic  form  usually  follows  the  acute  variety,  the  symptoms 
being  less  severe,  but  persistent.  Loss  of  strength  and  emaciation 
become  extremely  pronounced.  The  temper  is  very  irritable;  the 
complexion  grows  dark,  sallow,  and  unhealthy,  and  the  face  presents 
the  "old  man"  appearance;  the  skin  is  dry  and  harsh,  and,  in  conse- 
quence of  the  marked  emaciation,  either  hangs  in  folds  around  the 
shrunken  limbs  or  is  drawn  tightly  over  the  joints;  the  abdomen  is 
enlarged  and  tender,  the  stools  numbering  from  sLx  to  a  dozen  during 
the  day  and  night,  consisting  of  the  products  of  an  imperfect  digestion 
mixed  with  mucus,  serum,  pus,  and  oftentimes  blood,  ha\'ing  a  semi- 


26o  ENTEROCOLITIS 

fluid  consistency,  and  an  extremely  offensive  odor.  Ulcerative 
stomatitis  is  a  frequent  complication,  adding  to  the  discomfort  of 
the  patient.  An  irregular  temperature  record  may  occur  with  in- 
creased frequency  of  the  pulse. 

In  fatal  cases,  the  termination  is  ushered  in  with  delirium, 
convulsions,  stupor,  coma,  and  other  symptoms  resembling 
hydrocephalus. 

Diagnosis. — The  distinctive  features  of  this  affection  are  the  fever, 
abdominal  distention  and  tenderness,  emaciation,  and  the  character- 
istic "chopped  spinach"  stools.  Cholera  infantum  may  be  confused 
with  it,  but  the  rapid  onset,  high  temperature,  persistent  vomiting, 
profuse  serous  stools,  and  early  collapse  in  the  former  affection  will 
serve  to  differentiate  these  conditions. 

Prognosis. — Enterocolitis  is  always  a  serious  affection.  The  acute 
cases  usually  subside  in  from  ten  days  to  two  weeks,  while  the  chronic 
forms  last  from  one  to  three  months  or  longer.  Relapses  are  frequent. 
In  vigorous  children  who  have  passed  their  first  dentition  the  outlook 
is  favorable,  but  in  weak  infants  surrounded  by  unhygienic  environ- 
ments, the  prognosis  is  grave.  The  prompt  institution  of  appropriate 
treatment  favorably  influences  the  prognosis. 

Treatment. — The  feeding  should  be  flrst  temporarily  withheld 
and  afterward  altered  to  suit  the  individual  needs  of  the  patient. 
When  possible,  a  change  of  air,  with  cleanHness  and  rest,  is  desirable. 
The  intense  suffering  of  the  little  patients  calls  for  anodjnies,  and  the 
progressive  emaciation  indicates  the  use  of  whiskey  or  brandy  (lo 
to  20  minims)  every  three  or  four  hours.  The  following  formulas 
may  also  be  used  with  advantage: 

I^.     Salol gr.  ij  0.13  gm. 

Bismuth  subnitrat gr.  v  0.32  gm. 

M.     Ft.  chart.  No.  j. 
S. — Such  a  powder  every  two  hours. 
Or— 

I^.     Hydrarg.  chlorid.  mit gr.  ss  0.032  gm. 

Pulv.  ipecac gr.  ss  0.032  gm. 

Pulv.  opii gr.  ss  0.032  gm. 

Cretae  prseparat gr.  xx  1.3      gm. 

M.     Ft.  chart.  No.  xij. 

S.— One  every  two  or  three  hours,  to  child  of  one  year. 

The  compound  kino  powder,  lactic  acid,  and  subnitrate  of  bismuth 
in  small  but  frequently  repeated  doses  may  be  of  benefit. 


ENTEROCOLITIS  26 1 

The  following  is  a  good  combination: 

I^.     Bismuthi  subnitrat 3iij  12  gm. 

Tinct.  kino f  S  jss  45  c.c. 

Tinct.  opii  camphorat f  Sjss  45  c.c. 

Mist,  cretae §iij  90  c.c. 

M.  S. — Tablespoonful  every  few  hours. 

Flushing  of  the  colon  with  cold  normal  salt  solution,  or  solutions 
containing  silver  nitrate  (i  gr.  to  the  ounce),  tannic  acid  (5  gr.  to 
the  ounce),  or  sodium  benzoate  (4  gr.  to  the  ounce)  is  an  extremely 
valuable  part  of  the  treatment.  For  tenesmus,  Rotch  advises  sup- 
positories containing  yi  gr.  of  cocaine.  The  abdominal  pain  and 
distress  may  be  relieved  by  the  application  of  hot  water-bottles, 
mustard  plasters,  turpentine  stupes,  or  the  spice  poultice.  The 
spice  poultice  is  made  up  of  },i  ounce  (15.6  gm.)  each  of  cloves,  all- 
spice, cinnamon,  and  anise  seeds,  which  are  pounded  together  in  a 
mortar  and  placed  between  two  pieces  of  coarse  flannel  about  6  inches 
-square.  This  should  be  soaked  in  equal  parts  of  hot  whiskey  or 
brandy  and  water  and  then  applied  to  the  abdomen,  being  again 
heated  as  it  becomes  cool. 

The  chronic  form  differs  but  slightly  in  its  treatment  from  the 
acute  form.  The  diet  requires  considerable  attention,  to  alter  and 
predigest  the  artificial  foods  to  meet  the  various  indications.  Fresh 
air,  salt  baths,  cleanliness,  and  other  details  of  hygiene  demand  con- 
sideration. Among  drugs,  bismuth,  pepsin,  and  salicin  will  be  found 
of  benefit.     The  following  formulas  may  also  be  employed: 

I^.     Argenti  nitrat gr.  j  0.065  §"!• 

Acid,  nitric,  dil ITlxv  i  .0      c.c. 

Mucil.  acacise f§ss  15.0      c.c. 

Aq.  cinnamomi ad  f giij  ad  90.0      c.c. 

M.    S. — Teaspoonful,    diluted,    every  three   or  four   hours. 
Or— 

I^.     Acidi  carbolici gr.  Jf  2  to  3^  0.005  to  0.008  gm. 

Tincturse  iodi TTlj  to  ij  o .  06    to  0 .  12    c.c. 

Aquas  menthse  pip f5j  4.0                       c.c. 

M.  S. — Every  three  or  four  hours. 
Or— 

I^.     Quininae  hydrochlorid gr.  xxv  i  .6  gm. 

Acid,  tannici gr.  x  0.6  gm. 

Syr.  limonis f5ij  8.0  c.c. 

Aq.  chloroformi. .  .  .q.  s.  ad  f5iij  ad              12.0  c.c. 
M.  S. — Teaspoonful  every  two  hours. 


262  CHOLERA   INFANTUM 


CHOLERA  INFANTUM 

Synonjmis. — Choleriform   diarrhea;   summer   complaint. 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  stomach  and  intestines,  together  with  an  irrita- 
tion of  the  sympathetic  nervous  system,  occurring  in  children  during 
the  first  dentition;  characterized  by  severe  colicky  pains,  vomiting, 
purging,  febrile  reaction,  and  prostration. 

Causes. — Hot  weather,  infancy,  dentition,  improper  food,  bad 
hygiene,  and  constitutional  predisposition  are  the  most  important 
causes.  The  exciting  cause  is  probably  some  specific  microorgan- 
ism or  its  toxin.  Several  varieties  of  bacteria  have  been  found  in 
this  disease,  but  no  one  alone  has  as  yet  been  identified  as  the  cause. 

Pathological  Anatomy. — There  are  no  characteristic  lesions,  the 
gastrointestinal  mucous  membrane  is,  however,  usually  the  seat  of 
catarrhal  inflammation. 

S3nnptoms. — The  onset  is  sudden,  being  ushered  in  with  vomiting, 
purging,  abdominal  pain,  high  fever  (103°  to  io5°F.),  rapid  pulse, 
and  intense  thirst.  The  vomited  matter  consists  of  partly  digested 
food,  sero-mucus,  and  finally  bilious  material.  Distressing  retch- 
ing accompanies  the  vomiting.  The  tongue  is  coated.  Thirst  is 
a  marked  feature  of  the  disease,  and  ice  and  water  will  be  taken 
incessantly  for  its  relief  only  to  be  rejected  a  few  minutes  later. 
The  stools  are  first  partly  fecal,  but  soon  become  watery  or  serous, 
soaking  the  clothing  and  leaving  a  faint  greenish  or  yellowish  stain. 
They  number  from  ten  to  twenty  a  day  and  possess  a  musty  and  at 
times  fetid  odor.  The  temperature  should  be  taken  in  the  rectum, 
as  the  surface  temperature  is  comparatively  low.  The  pulse  is  rapid 
and  feeble,  ranging  from  130  to  160  per  minute.  These  various 
symptoms  continue  but  a  few  hours  before  rapid  wasting  ensues. 
The  body  shrinks,  the  eyes  are  shrunken  and  partly  closed,  the  mouth 
partly  open,  and  the  lips  are  dry,  cracked,  and  bleeding.  The  child 
is  at  first  irritable  and  restless,  but  soon  passes  into  a  semicomatose 
condition,  the  pulse  becoming  more  and  more  feeble;  the  body  sur- 
face is  cold  and  clammy;  the  pupils  contract,  but  are  irresponsive 
to  light;  and  the  stupor  deepens.  The  termination  may  be  in  death 
with  profound  exhaustion  or  convulsive  seizures,  or  in  recovery,  the 
symptoms  gradually  ameliorating  and  passing  into  a  slow  and  tedious 
convalescence. 


CHOLERA   INFANTUM  263 

Diagnosis. — The  characteristics  of  cholera  infantum  which  serve 
to  distinguish  it  from  other  enteric  affections  are  the  rapid  onset, 
the  constant  serous  vomiting  and  purging,  the  intense  thirst,  the 
high  fever,  prostration,  and  rapid  emaciation. 

Prognosis. — The  outlook  is  unfavorable.  Many  cases  end  by 
collapse  within  twenty-four  to  forty-eight  hours.  The  choleraic 
symptoms  never  last  more  than  five  days,  and  if  the  patient  survives 
this  period,  recovery  after  a  protracted  convalescence  is  probable. 
Relapses  are  common. 

Treatment. — The  first  indication  is  to  thoroughly  empty  the 
digestive  tract  by  washing  out  the  stomach  and  irrigating  the 
bowel  with  cold  water.  Morphine,  gr.  ^00  (0.00065  gm.),  and 
atropine,  gr.  3^00  (0.000132  gm.),  may  be  given  hypodermically  to 
a  child  one  year  old,  to  combat  the  nervous  and  cardiac  symptoms. 
Normal  salt  solution  should  be  administered  by  the  bowel  or  by  hypo- 
dermoclysis.  The  fever  will  require  cool  bathing,  or  sponging  with 
alcohol  and  water,  and  the  application  of  an  ice-bag  to  the  head.  In 
the  early  stages  it  is  best  to  withhold  feeding;  later  brandy,  T([v  to 
X  (0.3  to  0.6  c.c),  and  barley  water  should  be  given  every  hour.  If 
the  stomach  is  absolutely  unretentive,  the  stimulation  should  be 
administered  hypodermically.  The  vomiting  may  be  controlled  to 
a  greater  or  less  extent  by  large  doses  of  bismuth  or  chloral,  gr.  j 
to  iij  (0.065  to  0.21  gm.),  by  the  mouth  in  a  demulcent,  or  double 
the  quantity  by  the  rectum,  or  one  of  the  following : 

I^.     Bismuth,  subnitrat 5ij  8.0      gm. 

Acid,   carbolic gr.  j  0.065  gm. 

Mist,  acacias, 

Aq.  menth.  pip aa  fBj  aa  30.0     c.c. 

M.   S. — Teaspoonful  every  half  hour,  hour,  or  two  hours. 
Or— 

I^.     Hydrarg.  chlorid.  mit gr.  J^o  0.003            gm. 

Bismuth,  subnitrat gr.  ij  to  v  o .  13  to  o .  3  gm. 

M.  S. — A  powder  every  half  hour. 

Benefit  may  also  be  obtained  from  the  use  of  bismuth  salicylate, 
gr.  ij  (0.13  gm.),  with  sugar  of  milk  every  hour  or  two,  or  salol,  gr. 
j  to  ij  (0.065  "to  0.13  gm.),  every  two  or  four  hours.  When  depression 
supervenes  the  feeding  should  be  every  two  hours;  water  or  ice 
should  be  given  to  quench  the  thirst;  and  cognac  brandy,  lUv  to  x 
(0.3  to  0.5  c.c),  should  be  administered  every  hour  or  two  by  the 


264  APPENDICITIS 

mouth,  rectum,  or  hypodermic  injection.  In  the  event  of  collapse, 
the  hot  bath  should  be  employed  and  a  hypodermic  injection  of 
str^^chnine  (gr.  Hoo  oi"  0.00065  gm.  to  a  one-year-old  child),  should 
be  given.  The  nervous  symptoms  when  marked  may  require 
potassium  bromide  or  valerian. 

Locally,  the  application  of  hot-water  bottles,  mustard  or  spice 
poultice,  or  turpentine  stupes  to  the  epigastrium  will  afford  reUef. 

During  convalescence  a  change  of  air  is  of  great  benefit.  Every 
detail  of  the  hygiene  should  be  improved.  Peptonized  milk  should 
be  given  for  a  long  period,  substituted  occasionally  by  barley-water, 
albumin- water,  and  fresh  beef-juice.  The  feeding  should  be  care- 
fully watched  and  modified  from  time  to  time  as  the  occasion  arises. 

APPENDICITIS 

Synonyms. — Perityphlitis;  typhlitis. 

Definitions. — Typhlitis  really  means  inflammation  of  the  cecum. 
Perityphlitis,  an  acute  inflammation  of  the  connective  tissue  around 
the  cecum. 

Appendicitis. — An  acute  or  subacute  inflammation  of  the  appendix 
vermiformis,  involving  the  surrounding  tissues.  But  typhlitis  is 
merely  an  extension  of  appendicitis,  and  the  term  should  be  abolished. 

Causes. — Fecal  impaction,  foreign  bodies,  errors  in  diet,  acute 
indigestion,  exposure,  intestinal  catarrh,  male  sex,  early  adult  life 
and  the  peculiar  anatomy  of  the  appendix  are  the  principal  predispos- 
ing causes.  The  exciting  cause  is  a  microorganism,  in  all  probability 
the  Bacillus  coH  communis,  but  streptococci,  staphylococci,  and  the 
Proteus  vulgaris  have  been  associated  with  it.  It  may  follow  tubercu- 
losis, typhoid  fever,  or  influenza,  in  which  cases  the  exciting  cause  is 
probably  the  bacterium  which  produced  the  preceding  infectious 
fever.     Torsion  of  the  appendix  may  be  a  cause. 

Pathological  Anatomy. — The  inflammation  of  the  appendix  may 
be  catarrhal,  ulcerative,  or  interstitial. 

Catarrhal  appendicitis  consists  in  a  desquamative  inflammation 
of  the  mucous  membrane,  which  becomes  swollen  and  sometimes 
obliterates  the  lumen  of  the  tube.  In  some  cases  the  excoriated 
surface  becomes  the  avenue  of  infection  and  the  disease  terminates 
in  an  acute  infectious  peritonitis. 

Ulcerative  appendicitis  is  characterized  by  varying  grades  of 
ulceration  of  the  mucous  membrane  and  submucous  tissue,  and  may 
terminate  in  perforation.     It  is  not  infrequently  associated  with 


APPENDICITIS  265 

fecal  concretions  and  foreign  bodies.  Typhoid  and  tuberculous  ulcera- 
tions may  be  encountered. 

Interstitial  or  parietal  appendicitis  may  have  its  origin  in  an  abraded 
or  ulcerated  surface  of  the  mucous  membrane,  or  it  may  arise  inde- 
pendently in  the  structure  of  the  appendix  wall,  the  infection  being 
carried  by  the  lymphatics.  It  is  extremely  virulent  and  is  commonly 
associated  with  necrosis  or  gangrene  of  the  appendix  wall,  thereby 
leading  to  perforation  and  a  virulent  type  of  peritonitis.  It  may 
terminate  fatally  before  the  necrosis  becomes  manifest. 

In  all  forms  there  is  a  localized  or  generalized  peritonitis,  which, 
by  its  resultant  adhesions,  aims  to  wall  off  the  infection  from  the 
general  peritoneal  cavity.  In  the  mild  forms  this  is  accomplished 
to  a  great  extent,  but  in  severe  cases  in  which  pus  forms  and  the 
appendix  ruptures,  these  adhesions  for  a  time  form  the  walls  of  an 
abscess;  but  they,  too,  ultimately  rupture,  discharging  the  contents 
of  the  abscess  into  the  peritoneal  cavity,  bowel,  bladder,  vagina,  or 
externally.  Sometimes  the  exudate  into  the  tissues  surrounding  the 
appendix  is  absorbed. 

Symptoms. — The  affection  begins  with  a  feeling  of  weight  and 
soreness  and  rapidly  developing  severe  pain  over  the  entire  abdomen, 
but  most  marked  in  the  right  iliac  region.  The  pain  is  increased  by 
coughing,  deep  breathing,  and  by  lying  on  the  left  side,  so  that  for 
relief  the  right  leg  drawn  up  and  the  dorsal  decubitus  assumed. 
Localized  tenderness  accompanies  the  pain  and  corresponds  to  the 
situation  of  the  diseased  structure.  Usually  it  may  be  detected 
by  palpation  at  a  point  midway  between  the  umbilicus  and  the  an- 
terior superior  spine  of  the  ilium  (McBurney's  point).  In  the  early 
stage,  there  is  rigidity  of  the  right  abdominal  rectus  muscle  and  adja- 
cent muscles,  which  rigidity  is  replaced  in  two  or  three  days  by  an 
oval  tumor,  usually  about  the  size  of  a  hen's  egg,  lying  in  the  right 
iliac  region,  parallel  to  Poupart's  ligament.  Percussion  over  this 
enlargement  yields  impaired  resonance  or  dullness.  Occasionally 
the  note  is  normal.  Nausea  and  vomiting  are  frequent  and  often 
occur  early  in  the  attack.  The  tongue  becomes  coated  and  the  appe- 
tite is  lost.  Constipation  is  the  rule,  but  it  may  be  replaced  by  diar- 
rhea. Fever  (102°  to  io4°F.)  is  present  from  the  onset  and  may  or 
may  not  be  preceded  by  a  chill.  There  is  a  corresponding  increase 
in  the  pulse  rate.  Suppuration  is  usually  manifested  by  irregular 
fever  and  chills,  sweats,  and  a  feeling  of  tension  or  throbbing  in  the 
region  of  the  appendix,  but  may  be  unattended  by  fever.     Gangrene 


266  "         APPENDICITIS 

of  the  appendix  may  occur  in  the  presence  of  a  normal  temperature. 
A  sudden  fall  in  the  temperature  usually  indicates  perforation  of  the 
structure.  The  urine  has  the  characteristics  of  fever  urine,  and  in 
addition  contains  a  large  quantity  of  indican.  Leukocytosis  is  pres- 
ent in  most  cases. 

Complications. — Obstruction  of  the  bowels  is  the  most  important 
compHcation.  Local  or  general  peritonitis,  perforation,  and  abscess 
formation  are  the  most  common  complications.  LocaHzed  periton- 
itis gives  rise  to  adhesions  which  may  produce  intestinal  obstruction. 
Generalized  peritonitis  may  result  from  extension  of  the  inflammation 
or  rupture  of  the  appendix.  The  symptoms  of  the  resulting  general 
peritonitis  are:  ''(i)  Diffuse  pain,  as  contrasted  with  pain  localized 
in  the  right  iliac  region — pain  of  extreme  severity.  (2)  Generally 
distended  and  tender  abdomen.  (3)  Moderate  fever,  succeeded  by 
normal  or  subnormal  temperature,  which  may  often  mislead  the 
physician.  (4)  Rapid  and  feeble  pulse.  (5)  Dry  and  coated  tongue. 
(6)  The  phenomena  of  collapse — i.e.,  cold,  clammy  skin,  feeble  pulse, 
anxious  expression,  death." 

Suppuration  of  the  appendix  may  be  followed  by  generalized  peri- 
tonitis, hepatic  abscess,  lumbar  abscess,  perinephritic  abscess,  or 
multiple  pyemic  abscesses.  Chronic  appendicitis,  in  which  the 
attacks  recur  at  intervals,  is  a  common  sequel  in  cases  in  which  the 
appendix  is  left  undisturbed. 

Diagnosis. — The  diagnosis  is  often  difficult.  Sudden  pain,  ten- 
derness, muscular  rigidity,  and  fever  are  the  main  symptoms. 
Rovsing  ^s  sign  may  be  useful  in  differentiating  acute  appendicitis  from 
other  lesions  of  the  lower  abdomen  such  as  salpingitis. 

It  is  thus  given  by  Tyson:  "Pressure  over  the  descending  colon 
at  a  point  opposite  the  cecum  will  give  pain  in  the  appendix  region 
if  the  case  is  appendicitis,  but  will  not  give  pain  if  the  case  is  any  other 
lesion." 

Typhoid  fever  is  distingiiished  from  appendicitis  by  its  more 
gradual  onset,  the  characteristic  temperature  record,  diarrhea, 
enlargement  of  the  spleen,  rose-colored  abdominal  rash,  and  the 
Widal  reaction. 

Intestinal  obstruction  is  unattended  by  fever,  there  is  no  localized 
tenderness,  constipation  is  more  complete,  the  pain  is  diffuse,  and 
the  vomiting  may  be  stercoraceous. 

Rectal  growths,  tubal  disease,  and  ovarian  tumors  may  be  recognized 
and    differentiated    from    appendiceal  inflammation    by    physical 


APPENDICITIS  267 

examination  by  rectum  and  vagina;  and  see  Rovsing's  sign  above. 

Acute  indigestion  is  characterized  by  an  absence  of  localized  pain 
and  tenderness.  Diarrhea  is  common  and  there  is  no  enlargement 
of  the  right  iliac  region. 

Hepatic  colic  is  attended  by  jaundice  and  intermittent  pain  higher 
up  in  the  abdomen  extending  to  the  right  shoulder.  Fever  is  usually 
absent. 

Nephritic  colic  is  marked  by  an  absence  of  fever  and  localized 
rigidity  and  by  paroxysmal  pain  extending  from  the  lumbar  region 
into  the  groin  and  testicle. 

Hepatic  and  renal  abscesses  may  be  distinguished  by  their  location 
and  character  of  the  pain.  They  often  occur  as  the  result  of  a  sup- 
purating perityphlitis  and  frequently  are  only  recognized  after  the 
abdomen  has.  been  opened. 

Prognosis. — The  outlook  depends  entirely  on  the  character  of 
the  disease  and  the  treatment.  In  non-suppurative  cases  recovery 
is  the  rule.  Suppurative  cases,  in  which  surgical  treatment  has  been 
instituted,  show  a  mortality  of  about  25  per  cent.  The  mortality 
is  7 5  per  cent,  in  the  presence  of  generalized  peritonitis.  In  operations 
between  the  attacks  the  mortality  is  less  than  i  per  cent. 

Treatment. — As  soon  as  the  diagnosis  has  been  made  (and  even 
before  this)  a  competent  surgeon  should  be  associated  with  the 
physician,  as  it  is  difficult  to  predict  the  termination  even  in  ap- 
parently mild  cases.  The  patient  should  be  placed  at  rest  in  bed  and 
the  diet  restricted  to  liquids.  In  the  early  stages  a  mild  laxative, 
such  as  castor  oil,  calomel,  or  citrate  of  magnesia  may  be  administered. 
In  advanced  cases  purgation  may  induce  perforation.  Enemas 
may  be  cautiously  used.  Heat  or  cold  applied  to  the  abdomen  will, 
in  a  measure,  relieve  the  pain.  Morphine,  hypodermically,  may  be 
necessary,  but  it  should  be  remembered  that  it  masks  important 
symptoms.  If  the  symptoms  do  not  subside  under  this  plan  of 
treatment  within  twenty-four  or  forty-eight  hours,  it  is  customary 
to  resort  to  a  surgical  operation.  Some  surgeons  operate  as  soon  as 
the  diagnosis  is  made.  In  mild  cases  in  which  the  symptoms  abate 
and  the  attack  is  the  first  one,  the  operation  may  be  postponed  until 
the  interval  between  the  attacks.  If  the  symptoms  become  less 
in  severity,  but  do  not  entirely  subside,  operation  is  indicated  at 
once.  Complicated  cases  also  require  immediate  operation.  No 
definite  rules  can  be  followed  in  appendicitis,  each  case  possessing 
features  which  place  it  in  a  class  by  itself.     In  cases  in  which  it  is 


268  PROCTITIS 

certain  an  operation  will  not  be  performed,  counterirritation  may 
be  applied  to  the  abdomen. 

PROCTITIS 

Synonyms. — Catarrh  of  the  rectum;  dysentery;  rectitis. 

Definition. — A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  rectum  and  anus;  characterized  by  pain,  tenesmus,  and 
frequent  stools  of  hardened  feces,  or  of  mucus,  pus,  and  blood. 

Causes. — It  may  arise  from  constipation,  habitual  use  of  enemas 
and  purgatives,  diseases  of  the  liver,  hemorrhoids,  and  sitting  on 
damp  ground  or  stone  steps. 

Sjmiptoms. — Burning  pain  in  the  rectum,  tenesmus,  the  passage 
of  hardened  feces,  or  stools  containing  mucus,  mucopus,  or  blood, 
and  prolapse  of  the  mucous  membrane  are  the  most  prominent 
symptoms.  Nausea,  headache,  feverishness,  and  malaise  may  be 
present.  In  severe  cases  strangury  and  vesical  tenesmus  may  be 
present,  and  periproctitis  and  fistulas  may  occur  if  the  affection  is 
protracted.  Hepatic  abscess  and  peritonitis  may  arise  as  complica- 
tions. 

Diagnosis. — Physical  examination  of  the  rectum  will  serve  to 
distinguish  it  from  hemorrhoids  and  uterine  displacements,  which 
are  somewhat  similar  as  regards  their  symptomatology. 

Prognosis. — The  outlook  is  favorable  in  uncomplicated  cases. 

Treatment. — As  constipation  is  the  most  common  cause  it  should 
be  relieved  by  a  soap  and  warm  water  enema,  rectal  irrigations,  or 
the  following  injection: 

I^.     Magnesii  sulphat 5ij  60  gm. 

Glycerini f  5ss  15  c.c. 

Aquce  bul f  §iv  120  c.c, 

M.  S. — Use  as  directed. 

Glycerin  may  be  employed  in  suppository  or  enema,  or  the  follow- 
ing emollient  enema  may  be  used : 

I^.     01.  olivae fgij  60  c.c. 

Tinct.  opii  deodorat TTlxv  i  c.c. 

M.  S. — Use  as  directed. 

Hot  injections  of  strong  black  coffee,  using  from  a  half  pint  to  a 
quart,  are  valuable  in  irritability  of  the  rectum  with  a  tendency  to 
diarrhea.     Occasionally  cold  injections  are  more  beneficial. 


INTESTINAL  OBSTRUCTION  269 

If  periproctitis  and  suppuration  supervene  early  incision  is 
indicated. 

INTESTINAL  OBSTRUCTION 

Definition. — A  sudden  or  gradual  closure  of  the  intestinal  canal; 
characterized  by  pain,  nausea,  vomiting,  constipation,  and  finally 
collapse.  Obstruction  to  the  descent  of  fecal  matter  is  the  main 
idea;  but  frequent  loose  bowel  movements  may  occur  in  intussuscep- 
tion and  other  forms. 

Varieties. — (a)  Acute  obstruction,  produced  by  (i)  strangulation, 
(2)  intussusception  (or  invagination) ,  (3)  twists  and  knots  (volvulus), 
(4)  foreign  bodies,  (5)  strictures,  and  (6)  morbid  growths.  Acute 
obstruction  usually  involves  the  small  intestine. 

{b)  Chronic  obstruction,  produced  by  (i)  fecal  impaction,  (2) 
strictures,  (3)  morbid  growths.  Chronic  obstruction  involves  the 
large  intestine. 

Causes. — The  numerous  causes  are  arranged  as  follows: 

1.  Strangulation  is  the  most  frequent  cause  of  acute  intestinal 
obstruction,  and  is  most  often  due  to  inflammatory  bands  or  adhesions, 
vitelline  remains,  adherent  appendix,  and  peritoneal  pouches  and 
openings.  Most  cases  occur  in  males,  and  after  the  twentieth  year; 
if  it  occurs  in  early  youth  it  is  usually  caused  by  vitelline  remains. 

2.  Intussusception  or  invagination  is  due  to  one  portion  of  the 
intestine  slipping  down  into  the  lumen  of  another  portion,  always 
from  above  downward;  it  may  even  protrude  at  the  rectum.  The 
external'  or  receiving  portion  is  the  intussuscipiens;  the  inner  parts 
form  the  intussusceptum. 

3.  Twists  and  Knots  {Volvulus). — As  a  rule,  the  intestine  is  twisted 
on  its  long  or  mesenteric  axis;  knots  occur  rarely.  It  is  most  fre- 
quent in  adult  males,  between  the  ages  of  thirty  and  forty;  and  the 
large  intestine  is  usually  involved. 

4.  Foreign  Bodies. — The  majority  of  these  are  gallstones  (and  these 
are  more  frequent  in  females) ;  but  lumbricoid  worms,  medicines  such 
as  large  doses  of  magnesia  and  bismuth,  and  rarely  substances  intro- 
duced by  the  mouth  (such  as  pennies,  buttons,  pins,  fruit  stones,  etc.) 
are  also  found. 

5.  Strictures  and  6.  Morbid  Growths. — These  occur  in  adults,  and 
are  generally  found  in  the  large  intestine.  Strictures  may  be  congeni- 
tal or  cicatricial;  the  latter  are  due  to  healed  ulcers,  tuberculous,  or 
syphilitic.     Morbid  growths  may  be  benign  or  malignant,  may  occur 


270  INTESTINAL   OBSTRUCTION 

within  or  without  the  lumen  of  the  intestine;  the  most  frequent  is 
epithelioma,  near  the  sigmoid  flexure. 

7.  Fecal  obstruction  occurs  more  often  in  females,  and  is  found  in  the 
large  intestine  (chiefly  the  lower  part) .  It  is  due  to  constipation,  chronic 
enteritis  and  peritonitis,  imperfect  digestion,  and  nervous  influences. 

Pathological  Anatomy. — Invagination  calls  for  special  description. 
It  is  usually  caused  by  the  lower  portion  of  the  ileum  slipping  down  into 
the  cecum,  as  the  finger  of  a  glove  might  be  invaginated,  causing  thus 
an  actual  mechanical  obstruction;  this  is  produced  by  a  spasm  of 
the  ileum,  whereby  its  caliber  is  greatly  diminished,  thus  permitting 
its  descent  into  the  lower  bowel.  Resulting  from  this  occlusion  or 
compression,  are  congestion,  inflammation,  wdth  secondary  constitu- 
tional reaction  and  death,  or  more  rarely  the  invaginated  bowel 
sloughs  off  and  is  voided  by  stool,  union  taking  place  at  its  site  and 
recovery  following. 

Symptoms. — In  acute  cases,  sudden  spasmodic  abdominal  pain 
which  soon  becomes  continuous  in  character  is  an  early  symptom. 
Constipation,  which  is  unrelieved  by  purgatives  or  enemas,  is  present; 
and  there  is  inability  to  pass  flatus.  The  abdomen  becomes  greatly 
distended  and  very  tender  in  spots.  Nausea  and  vomiting  occur, 
the  vomit  persisting  and  at  length  becoming  stercoraceous.  In 
intussusception,  there  is  a  characteristic  tumor,  generally  found  in  the 
left  iliac  region.  In  gallstone  obstruction,  jaundice  is  often  present. 
As  the  condition  progresses,  pinched  features,  sunken  eyes,  quick, 
feeble  pulse,  cold,  clammy  skin,  and  other  symptoms  of  collapse 
become  manifest.  The  duration  of  this  form  is  about  a  week,  or 
ten  days,  when  death  may  occur,  or  more  rarely  the  symptoms  may 
subside  and  there  is  a  gradual  return  to  health. 

In  chronic  cases  obstinate  constipation,  with  the  passage  of  rib- 
bon-shaped stools  or  scybalous  masses,  abdominal  pain  and  disten- 
tion and  failure  of  health  are  the  principal  symptoms.  The  onset 
is  gradual.  It  may  become  acute  when  the  obstruction  is  complete. 
In  rare  instances  small,  fecal,  muco-purulent  stools,  containing  more 
or  less  blood,  are  passed. 

Diagnosis. — The  features  of  intestinal  obstruction  that  are  of 
most  value  in  making  a  diagnosis  are  the  obstinate  constipation,  the 
early  vomiting,  which  shortly  becomes  stercoraceous  in  character, 
the  abdominal  distention,  the  absence  of  any  discharge  of  flatus  by 
the  bowel,  and  early  collapse.  The  x-ray  may  aid  in  locating  the 
obstruction. 


INTESTINAL   OBSTRUCTION  27 1 

Acute  peritonitis  resembles  intestinal  obstruction  to  some  extent, 
but  the  fever,  diffuse  tenderness,  and  the  absence  of  a  tumor  and  fecal 
vomiting  point  to  peritonitis. 

Strangulation  in  hernia  is  attended  by  the  same  symptoms  as  in- 
testinal obstruction,  and  in  the  event  of  their  occurrence  the  various 
abdominal  rings  should  be  carefully  examined.  The  less  common 
situations  of  hernia,  such  as  the  obturator  foramen  and  the  sciatic 
notch,  should  also  be  investigated.  Sometimes  internal  strangula- 
tion results  from  a  portion  of  the  intestine  slipping  through  the  fora- 
men of  Winslow,  the  diaphragm,  or  a  slit  in  the  omentum  or  mesentery, 
or  under  Meckel's  diverticulum,  or  from  inflammatory  ad- 
hesions. 

The  situation  of  the  obstruction  may  be  indicated  by  the  presence  of 
a  tumor.  Fecal  vomiting  usually  points  to  obstruction  of  the  small 
intestine.  Active  peristalsis  is  always  present  a  short  distance  above 
the  obstruction. 

The  nature  of  the  obstruction  in  many  instances  may  be  determined 
indirectly.  In  the  large  intestine  more  than  one-half  the  cases  of 
obstruction  are  due  to  intussusception,  about  one-third  to  twists,  and 
about  one-eighth  to  stricture  and  tumors.  In  the  small  intestine 
nearly  three-fourths  of  the  cases  result  from  strangulation,  about  one- 
sixth  from  gallstones,  and  about  one-twelfth  from  intussusception. 
In  children  intussusception  is  the  most  common  cause  of  obstruction. 
It  may  be  recognized  by  the  sausage-shaped  tumor  along  the  colon, 
and  by  digital  examination  by  the  rectum.  Obstruction,  due  to 
twists,  malignant  growths,  and  strictures  is  usually  low  down  and 
may  be  detected  by  rectal  examination.  The  history  of  attacks  of 
peritonitis  will  point  to  inflammatory  adhesions  as  the  cause  of  the 
obstruction.  Alteration  in  the  thoracic  percussion-note  will  indicate 
thQ  passage  of  a  portion  of  the  bowel  through  the  diaphragm.  Marked 
meteorism  in  the  right  inguinal  region  is  considered  to  be  a  diagnostic 
symptom  of  obstruction  by  Meckel's  diverticulum.  Fecal  impaction 
is  distinguished  by  its  gradual  onset  and  course,  the  history,  and 
of  an  irregular  tumor  along  the  line  of  the  colon. 

The  table  on  page  272  will  aid  in  making  a  diagnosis. 
Prognosis. — The  prognosis  is  always  grave  but  is  most  favorable 
in  fecal  impactions.  In  invagination  the  outlook  is  less  favorable, 
but  recoveries  occur;  the  longer  the  symptoms  continue  the  more 
favorable  becomes  the  prognosis.  Strangulation  and  stricture  are 
very  grave  conditions. 


272 


INTESTINAL   OBSTRUCTION 


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TAPEWORMS — CESTODES  273 

Treatment. — In  all  acute  forms  of  obstruction,  food  and  cathartics 
should  be  withheld.  Morphine  and  atropine,  hypodermically,  and 
warm  applications  to  the  abdomen  will  be  required  to  relieve  the  pain. 
The  stomach  should  be  washed  out  two  or  three  times  daily,  and  in 
doubtful  cases  the  colon  may  be  irrigated  with  warm  water.  Disten- 
tion of  the  colon  with  gas  may  be  employed  in  suspected  intussuscep- 
tion. Nutrient  enemas  may  be  resorted  to  to  sustain  the  patient. 
An  abdominal  operation,  performed  early,  is  perhaps  the  best  treat- 
ment in  acute  cases. 

In  chronic  obstruction,  efforts  should  be  made  to  remove  the  fecal 
tumor.  Large  rectal  injections  of  warm  water  or  warm  oil  are  very 
efficient.  The  administration  of  calomel,  gr.  }i  (0.008  gm.),  every 
hour  is  an  additional  aid.  The  rectal  scoop  may  be  employed  if  the 
obstruction  is  low  down.  Massage  and  electricity  are  often  of  value. 
Surgical  intervention  may  be  necessary. 

INTESTINAL  PARASITES 

Parasites  are  low  forms  of  organisms  (animal  or  vegetable)  which 
live  in  or  on  other  animals  (called  the  host),  and  deriving  their  nourish- 
ment from  the  tissues  and  juices  of  their  host.  That  part  of  the  body 
of  the  host  in  which  the  parasite  takes  up  its  abode  is  called  its  habi- 
tat. The  organism  in  which  the  immature  forms  are  lodged  is  called 
the  intermediate  host. 


TAPEWORMS— CESTODES 

Varieties. — There  are  several  varieties  of  tapeworm  which  infest 
man,  but  only  the  following  are  of  importance:  Tcenia  saginata; 
Tcenia  solium;  Dibothriocephalus  latus;  Tcenia  echinococcus. 

Natural  History. — In  most  cases  the  lower  animals  are  the  inter- 
mediary hosts  by  ingesting  food  infected  by  the  tapeworm.  The 
embryos  or  proscolices  of  these  parasites  are  liberated  in  the  stomach 
and  from  thence  migrate  to  the  muscles  and  various  organs,  becoming 
encapsulated,  constituting  scolices,  or  cysticerci.  Meat  infected  by 
these  encysted  larvae  is  said  to  be  ''measly."  When  ingested  by  man 
the  capsules  are  dissolved  and  the  scolices  are  liberated  and  become 
attached  to  the  mucous  membrane  of  the  digestive  tract  and  there 
develop  into  mature  tapeworms. 
ig 


274 


TAPEWORMS — CESTODES 


Causes. — The  Tcenia  saginata,  called  also  the  Tcsnia  medio-canellata, 
the  "unarmed  tapeworm,"  is  derived  from  the  embryos  contained  in 
beef,  known  as  Cysticercus  hovis.  This  is  the  form  most  frequently 
met  with  in  this  country. 

The  Tcenia  solium,  the  "armed  tapeworm,"  is  extremely  rare  in  this 
country;  the  popular  impression  that  it  is  quite  common  is  errone- 


PiG.  21. — Tapeworms.  A.  i,  2  and  3,  Scolex,  proglottides  and  ovum  of  Tcenia 
solium;  B.  4,  5,  6  and  7,  Scolex,  proglottides  and  ovum  of  Dibothriocephalus  latus; 
C.  8,  9  and  10,  Scolex,  proglottides  and  ovum  of  Tania  saginata.  {From  Stiit's  Practical 
Bacteriology.)  . 


ous.  It  is  derived  from  the  embryos  contained  in  pork,  known  as 
the  Cysticercus  celluloses. 

The  Dibothriocephalus  latus,  or  Bothriocephalus  latus,  also  an  ''un- 
armed tapeworm,"  the  largest  parasite  infesting  man,  is  supposed  to 
be  derived  from  an  embryo  found  in  fish. 

The  Tcenia  echinococcus  occurs  in  its  natural  state  in  the  intestines 
of  the  dog,  the  larval  condition  only  being  encountered  in  man. 

Faulty  preparation,  improper  cooking,  and  lack  of  cleanliness  as 
regards  the  food  and  drink  are  important  etiological  factors. 


TAPEWORMS — CESTODES 


275 


Description. — The  Tcenia  saginala  or  Tcenia  mediocanellala  is  from 
10  to  30  feet  in  length,  and  has  several  hundred  proglottides.  It  has 
a  rounded  or  oval-shaped  head  which  measures  about  Ko  inch,  and 
has  four  strong  and  prominent  suckers,  but  no  booklets — whence  the 
term  ''unarmed  tapeworm;"  the  neck  is  short  and  thick  and  the  seg- 
ments are  larger,  stronger,  and  thicker  than  those  of  the  Tcenia  solium. 
The  best  way  to  distinguish  a  segment  of  Tcenia  saginata  from  that 
of  Tcenia  solium  is  to  count  the  number  of  lateral  uterine  branches. 

In  the  Tcenia  saginata,  there  are  15  to  30  of  them;  in  the  Tcenia 
solium  there  are  5  to  10.     (See  Fig.  21.) 

The  Tcenia  solium  seldom  exceeds  1 2  feet  in  length,  has  a  globular 
head,  or  scolex,  a  slender  neck,  connecting  its  numerous  flat  segments 
or  joints.  The  head,  or  scolex,  measures  about 
3^0  inch,  has  a  double  circle  of  booklets — whence 
the  term  "armed  tapeworm" — and  is  provided 
with  from  two  to  four  suckers.  The  segments 
or  joints  (strobila)  are  fiat,  and  vary  from  }4  to 
}'2  inch  in  length,  and  each  contains  both  male 
and  female  sexual  organs,  the  uterus  being  a  long, 
numerously  branched  tube,  in  which  the  ova 
develop;  the  ova  measure  about  H700  inch 
in  diameter.  An  ordinary  tapeworm  contains 
some  5,000,000  ova.  The  parasite  is  firmly  em- 
bedded in  the  mucous  membrane  of  the  upper 
third  of  the  small  intestines  by  its  booklets  and     Fig.  22.— Taenia  echin- 

ococcus.    {From  Greene  s 

suckers.     The  lower  or  terminal  segments  repre-  Medical  Diagnosis.) 
sent  the   adult    and   complete  animal,   and   are 
termed  the  proglottides,  which  separate    from  the  parasite  and  are 
discharged  either  alone  or  with  the  feces. 

The  Dibothriocephalus  latus  is  the  largest  of  the  three  cestodes, 
the  length  ranging  from  1 5  to  60  feet,  the  head  oval,  measuring  about 
Ko  inch,  a  short  neck,  the  segments  or  joints  being  nearly  three 
times  as  broad  as  they  are  long.  There  are  said  to  be  3000  or  more  of 
these  segments.     Its  color  is  a  dull  bluish-gray. 

The  Tcenia  echinococcus  is  one  of  the  smallest  tapeworms  known, 
being  about  %  inch  long,  and  is  composed  of  three  or  four  segments, 
of  which  only  the  end  segment  is  mature.  It  is  2  mm.  long  and  0.6 
mm.  wide  and  contains  about  5000  ova.  The  head  is  provided  with 
a  rostellum,  two  rows  of  booklets,  and  four  suckers.  The  adult 
worm  is  common  to  dogs  in  Iceland  and  Australia;  human  beings 


276  ROUND   WORMS — NEMATODES 

are  affected  only  by  the  embryos,  which,  on  being  liberated  in 
the  digestive  tract,  migrate  toward  the  periphery,  particularly  the 
liver,  where  they  form  hydatid  cysts.     (See  page  293.) 

Symptoms. — Not  infrequently  there  are  no  symptoms.  In 
many  cases,  colicky  pains,  inordinate  or  capricious  appetite, 
disorders  of  digestion,  emaciation,  anemia,  constipation,  cardiac 
palpitation,  faintness,  disorders  of  the  special  senses,  choreic 
movements,  convulsive  seizures,  and  pruritus  of  the  anus  and 
nose  are  present,  more  or  less  combined.  The  ingestion  of  a  large 
meal  often  removes  most  of  these  symptoms.  The  presence  of 
one  or  more  segments  of  the  tapeworm  in  the  stools  is  conclusive. 

Treatment. — This  consists  in  giving  first  something  to  paralyze 
the  worm,  and  then  something  to  expel  it.  The  administration  of 
an  anthelmintic  is  necessary  but  should  be  preceded  by  restriction 
of  the  diet  to  liquids  for  one  or  two  days  with  free  purgation.  Prob- 
ably the  best  teniafuge  is  oleoresin  of  aspidium,  f  3ss  (2  c.c),  alone 
or  in  combination. 

I^.     Oleoresinas  aspidii f5ij  8.0    c.c. 

Chloroformi f5ij  8.0    c.c. 

Olei  tiglii lUiv  0.24  c.c. 

Glycerini f §ij  60.0    c.c. 

M.   S. — Take  half  at  8  a.m.;  the  rest  in  an  hour  if  needed 
(Dock). 

Kousso,  S  j  (30  gm.),  in  a  half  pint  of  water,  fluidextract  of  the  bark 
of  the  root  of  pomegranate,  f  5ss  (2  c.c),  decoction  of  the  bark  of  the 
pomegranate  root — §j  (30  gm.)  to  the  pint  (480  c.c.)  of  water — in 
divided  doses,  or  the  tannate  of  pelletierine,  gr.  x  to  xx  (0.65  to  1.3 
gm.),  may  be  used  instead.  A  purgative  should  be  also  given  after 
the  anthelmintic  and  the  stools  carefully  watched  for  the  head  of 
the  parasite.  Sometimes  the  head  may  not  be  found,  because 
(being  very  small)  it  is  lost  in  the  discharges.  The  head  of  the 
Tcenia  solium  is  about  the  size  of  a  small  pin's  head;  in  the  TcBnia 
saginata  it  is  a  little  larger;  and  in  the  Dihothriocephalus  latus  it  is 
still  larger. 

ROUND  WORMS— NEMATODES 

General  Characters. — The  round  worms  are  round  and  thread 
like,  they  resemble  earthworms;  the  male  is  smaller  than  the  female; 
the  genital  pore  is  situated  in  the  female  about  the  middle  of  its  length, 
and  near  the  anus  in  the  male. 


ROUND    WORMS — NEMATODES 


277 


Varieties. — The  most  common  are:  Ascaris  lumhricoides;  Oxyuris 

vermicularis;    Trichina    spiralis;     Ankylostoma    duodenale;    Filaria 

sanguinis  hominis;  Trichocephalus  dispar. 

Causes. — The  Ascaris  lumhricoides  is  the  most 

common    of    the  parasites    affecting  the  human 

family,  and  develops  in  the  intestines,  either  after 

the  entrance  of  the  ova  of  the  same,  or  from  the 

so-called  "intermediate  parasites."     Their  entrance 

is  effected  by  means  of  the  food  and  drink. 

The  Oxyuris  vermicularis  develops  in  the  large  in- 
testines, from  either  its  peculiar  ova  or  the  so-called 

"intermediate  parasite,"  these  finding  their  way 

into  the  bowel  with  the  food  and  drink,  or  by  direct 

contact. 

The  Trichina  spiralis   is   introduced  into    the 

human    body    by    eating    infected    hog's    flesh, 

either  raw  or  but  partly  cooked. 

The     Ankylostoma    duodenale  gains    access    to 

the   digestive   tract  by  means   of  drinking  water    lumhricoides.    (a)  fe- 

infected    by    the    ova.     It    is    common    in   the    J^gg)  %  ""^h^ead! 

miners  and  brickmakers  in  Europe,   Egypt,  and     magnosis )^ ^ ^ ^ '^ '^ ^ 

India. 

The  filaria  sanguinis  hominis  is  common  in  tropical  coun- 
tries, the  medium  of  infection  being  con- 
taminated drinking  water.  The  parasites  are 
found  in  the  intestines  of  mosquitoes,  and  on 
the  sixth  or  seventh  day  of  their  development 
they  change  their  habitat  to  water,  through  the 
death  of  the. intermediary  host. 

The  Trichocephalus  dispar  is  one  of    the  most 
common  parasites  in  man,  having  for  its  habitat 
the  cecum.     The    ova   are   very  resistant  to  de- 
structive agents  and  are   found    in    large    num- 
FiG.  24.— Oxyuris   ^^^^   ^^    ^^^  fcccs.     Infcctcd   drinking    water    is 

vermicuians.   (a)  je-   probably  responsible  for  this  parasite  in  man. 

{Greene's       Medical       Description. — The    Ascaris   lumhricoides    looks 
very  much  like  the  ordinary  earthworm,  it  is  of 

a    brownish    color,    having    a    cylindrical    body,  pointed   at   both 

ends,   from   4  to  10  or  15  inches  in  length,  and    from    }^    to    >^ 

inch    in    circumference  the  head    terminates    in    three    semilunar 


278 


ROUND    WORMS — NEMATODES 


lips,  each  having  about  200  teeth.  The  ova  are  oval-shaped, 
are  produced  in  immense  numbers  (some  6o,qoo,ooo  in  a  mature 
female),  have  wonderful  vitality,  resisting  extreme  heat  or  cold. 
The  round  worm  inhabits  principally  the  small  intestines,  although 
it  often  migrates  to  other  parts.  They  are  found  in  numbers  from 
one  to  several  hundred. 

The  Oxyuris  vermicularis ,  thread,  or  seat  worm,  resembles  an 
ordinary  piece  of  white  thread,  measuring  from  %  to  >^  inch  in 
length,  the  head  terminating  in  a  mouth  with  three  lips,  the  tail 
terminating  as  a  sharp  point.  The  ova  are  oval,  produced  in  large 
numbers,  each  female  containing  about  ten  thousand,  and  are  sur- 
roimded  by  a  stout  envelope,  which  increases  their  vitality.     The  seat 


Fig.  25. — Trichina  spiralis,  (a)  en- 
cysted in  muscle,  (b)  male  adult,  (c) 
female  adult_  (personal  observation), 
(d)  male  genital  apparatus.  {Greene's 
Medical  Diagnosis.) 


Fig.  26. — Uncinaria  (ankylostoma) 
duodenale.  (a)  female,  (b)  male,  (c) 
eggs,  (d)  male  and  female  of  natural 
size.     (Greene's  Medical  Diagnosis.) 


worms,  as  the  name  indicates,  inhabit  the  large  intestines,  especially 
the  rectum,  although  they  frequently  migrate  to  the  sexual  organs. 
They  vary  in  number,  the  parts  frequented  being  entirely  covered. 

The  Trichina  spiralis  presents  itself  in  two  forms;  the  intestinal 
trichina  which  is  sexually  mature  and  the  muscle  trichina  which  is 
sexually  immature. 

The  Intestinal  trichina  is  a  small,  hair-like  worm,  the  male  measuring 
3^8  inch,  and  the  female  3^  inch  in  length;  the  head  is  smaller  than 
the  rest  of  the  body;  the  tail  of  the  male  has  a  bi-lobed  prominence, 
between  the  divisions  of  which  the  anal  opening  is  placed,  and  from 
which  a  single  spiculum  can  be  protruded;  the  female  has  a  blunt, 
rounded  tail,  the  reproductive  outlet  being  situated  toward  the  an- 


ROUND   WORMS — NEMATODES  279 

terior  part  of  the  body;  the  ova  are  very  small  (about  >f  70  inch  long), 
containing  embryos  which  are  produced  viviparously  at  the  rate  of  at 
least  100  each  week  after  the  entrance  of  the  female  into  the  intestinal 
canal. 

The  Muscle  trichina  develops  its  sexual  apparatus  after  it  has  entered 
the  intestinal  canal  of  the  host.  The  viable  embryos  discharged 
from  the  female  are  in  a  state  of  motion,  and  at  once  migrate  from  the 
intestines  to  the  muscular  structure  of  the  individual,  and  here  set 
up  inflammatory  action,  soon  becoming  surrounded  by  a  capsule  or 
shell  in  which  they  are  coiled.  After  a  time,  in  the  muscle,  the 
trichina  undergoes  a  further  change,  lime  salts  being  deposited  in  and 
about  the  capsule  and  in  the  parasite  itself,  when  minute  specks  of 
lime  are  seen  distributed  throughout  the  muscular  structure. 

The  development  of  the  parasite  from  the  period  of  impregnation 
up  to  time  of  sexual  maturity  is,  under  favorable  conditions,  less 
than  three  weeks.  Within  two  days  from  the  ingestion  of  the  infected 
pork  occurs  the  maturation  of  the  muscle  larvas;  in  six  days  more  the 
birth  of  embryos  occur,  and  in  about  two  weeks  the  migrating  progeny 
have  arrived  at  their  habitat,  the  muscular  structure. 

The  Ankylosfoma  duodenale  is  a  short,  white,  cylindrical  worm 
found  in  the  upper  part  of  the  small  intestine.  The  female  is  about 
y^  inch  long,  and  the  male  about  ^  inch. 

The  Filaria  sanguinis  hominis  is  an  extremely  small  parasite  and 
occurs  in  several  forms.  In  the  principal  form  {Filaria  Bancrofti 
or  Filaria  nocturna)  the  adult  male  is  83  mm.  long  and  0.4  mm.  wide; 
the  female  is  about  155  mm.  long  and  0.7  mm.  wide.  The  ovum  is 
0.038  mm.  long  and  0.014  mm.  wide.  The  adult  worm  is  found  usually 
in  the  lymphatics.  The  female  produces  an  enormous  number  of 
embryos  which  migrate  to  various  portions  of  the  body  and  are  found 
in  the  blood  stream  only  during  the  sleeping  hours,  usually  at  night. 

The  Trichocephalus  dispar  is  a  delicate,  hair-like  worm  4  to  5  cm. 
long,  the  posterior  two-fifths  being  the  thickest  portion.  The  ter- 
minal extremity  of  the  female  is  conical  and  pointed,  while  that  of 
the  male  is  obtuse  and  round.  The  ova  are  0.05  mm.  long  and  oval 
in  shape,  provided  with  a  small  teat-like  projection. 

Symptoms. — The  Ascaris  lumhricoides ,  may  be  present  in  great 
numbers  and  yet  produce  no  characteristic  symptoms  other  than  gas- 
tric and  intestinal  irritation,  causing  picking  the  nose,  foul  breath, 
colicky  pains,  nausea  and  vomiting,  diarrhea,  and  disturbed  sleep, 
such  as  tossing  from  side  to  side  in  bed  and  grinding  the  teeth.     Any 


28o  ROUND   WORMS — NEMATODES 

or  all  of  these  symptoms  may  be  present  or  absent;  a  positive  diagno- 
sis is  only  possible  upon  the  passage  of  the  parasite. 

The  Oxyuris  vermicularis,  or  seat  worm,  produces  intense  itching 
about  the  anus,  with  a  desire  for  stool,  the  passages  often  contain- 
ing much  mucus,  the  result  of  the  irritation  produced  by  the  para- 
site. Should  it  migrate  to  the  sexual  organs,  intense  itching  of  these 
parts  results,  which,  unless  speedily  corrected,  leads  in  children  to 
masturbation. 

The  group  of  phenomena  produced  by  the  Trichina  spiralis  is 
known  as  trichiniasis  and  presents  itself  in  three  stages. 

Intestinal  stage,  a  gastrointestinal  inflammation,  with  nausea,  vom- 
iting, and  watery  diarrhea,  the  severity  depending  upon  the  number 
of  the  parasites  ingested. 

Migration  stage,  a  typhoid-like  fever,  rapid,  feeble  pulse,  profuse 
sweats,  intense  thirst,  dry  tongue  and  lips,  and  red,  swollen  face,  with 
soreness  and  tenderness  of  the  muscular  structure,  increased  by  any 
muscular  act.     As  a  rule  the  mind  is  clear  but  decidedly  apathetic. 

Encapsulation  Stage. — If  the  number  of  parasites  ingested  has  been 
few,  recovery  may  occur  in  this  stage;  but  if  the  number  has  been 
large,  the  gastroenteritis,  fever,  and  muscular  phenomena  are  severe, 
the  patient  is  in  a  critical  condition,  between  20  and  50  per  cent, 
succumbing. 

Trichiniasis  may  resemble  typhoid  fever,  in  that  the  patient  has 
fever,  headache,  stupor,  pain  in  limbs,  back,  and  abdomen,  nausea  and 
diarrhea. 

In  trichiniasis,  there  is  an  eosinophilia;  therefore  in  all  suspected 
cases  a  differential  blood  count  should  be  made.  The  trichina  may 
be  found  in  muscle  tissues. 

The  Ankylostoma  duodenale  is  a  blood-sucking  parasite.  It  fastens 
itself  to  the  mucous  membrane  of  the  digestive  tract  and  at  first  pro- 
duces colicky  pains,  diarrhea,  and  other  symptoms  of  gastrointestinal 
irritation.  The  loss  of  blood  induced  by  the  parasite  leads  to  anemia 
(Egyptian  chlorosis,  tunnel  anemia),  emaciation,  and  weakness. 
This  disease  is  also  called  Uncinariasis,  or  Ankylostomiasis,  or  Hook- 
worm disease.  The  infection  may  be  carried  by  contaminated  food  or 
cistern  water,  also  (from  the  soil),  by  the  feet,  body,  or  dirty  clothes; 
thus  it  gains  entrance  through  the  skin.  The  parasites  inhabit  the 
intestinal  tract  and  their  ova  may  bs  found  in  the  stools.  The  dis- 
ease is  most  prevalent  in  the  southern  part  of  the  United  States  and 
in  some  instances  is  said  "to  have  followed  ground-itch.     Malaria 


ROUND   WORMS — NEMATODES  28 1 

may  be  associated.  The  principal  symptom  is  anemia  which  is  con- 
sidered by  most  observers  to  be  toxic  in  origin.  Leukocytosis  is 
uncommon,  but  an  increase  in  the  eosinophiles  is  rather  frequent. 
The  skin  has  a  dirty,  grayish  pallor  considered  by  many  to  be 
characteristic. 

The  Filaria  sanguinis  hominis  gives  rise  to  a  condition  known  as 
Filariasis  which  is  characterized  by  anemia,  enlargement  of  the  spleen, 
fever,  chyluria,  hematuria,  lymphatic  obstruction,  and  elephantiasis. 

The  Trichocephalus  dispar  may  be  unattended  by  symptoms,  or  may 
be  accompanied  by  slight  gastrointestinal  irritation,  anemia,  cerebral 
manifestations,  and  in  rare  instances  beri-beri. 

Treatment. — The  Ascaris  lumhricoides  is  readily  removed  by  the 
following  "worm  powder:" 

R.  Santonini gr.  M  to  j  to  ij  0.016  to  0.065  to  0.13  gm. 

Hydrarg.  chlorid.  mitis.  gr.  y^  to  ij  0.022  to  0.13  gm. 

M.     Ft.  chart. 
S. — At  bedtime,  followed  by  a  dose  of  castor  oil  before  breakfast. 

For  the  Oxyuris  vermicularis  the  above  santonin  powder,  with  the 
use  of  enemas  of  quassia,  alum,  salt,  or — 

I^.     Acidi  carbolici gr.  v  to  x    o .  3  to  o .  6  gm. 

Glycerin TTlv  to  x       o .  3  to  o .  6  c.c. 

Aquae Oj  480 .  o  c.c. 

M,  S. — For  rectal  injection. 

An  enema  of  corrosive  sublimate  (i  to  10,000)  is  sometimes  em- 
ployed. The  rectal  injection  should  not  be  retained  and  should 
always  be  preceded  by  a  large  enema  of  water  to  thoroughly  cleanse 
the  bowel.  Washing  of  the  anus  and  external  genitals  with  a  carbolic 
acid  solution  is  often  useful  and  aids  in  allaying  the  intense  itching. 

In  Trichiniasis,  the  pork  should  be  so  prepared  as  to  kill  any  exist- 
ing trichinae.  If  the  patient  is  seen  within  four  or  five  days  after  the 
ingestion  of  the  parasites,  emetics,  purgatives,  lavage,  and  intestinal 
irrigation  are  indicated.  Following  these  procedures  vermicides  may 
be  administered,  such  as  glycerin  (i  part)  and  water  (2  parts),  5  J  or 
4  c.c.  every  hour,  benzine,  3j  (4  gm.),  in  capsules,  quinine,  and  san- 
tonin. The  muscular  pains  may  be  relieved  by  hot  applications  and 
morphine  hypodermically.  Tonics  and  stimulants  are  necessary  to 
sustain  the  patient.     The  mortality  ranges  from  5  to  30  per  cent. 


282  DRACONTIASIS    (GUINEA    WORM   DISEASE) 

Ankylostomiasis  or  Uncinariasis  requires  thorough  boiHng  of  the 
drinking  water  in  districts  known  to  be  infected.  Thymol,  gr.  xxx 
(2  gm.),  in  divided  doses  followed  by  a  purgative,  seems  to  have  a 
specific  action;  filix  mas  is  also  used.  The  anemia  calls  for  rest,  iron, 
quinine,  strychnine,  arsenic,  etc.  Prophylaxis  includes  filtering  and 
boiling  water,  cleansing  of  all  vegetable  foods,  avoidance  of  going 
barefooted,  and  disinfection  of  stools  of  infected  persons.  Bathing 
and  the  wearing  of  clean  clothes  and  shoes  are  of  great  importance. 

Filar iasis  is  most  difficult  to  treat.  The  symptoms  should  be  met 
as  they  rise.  Thymol  and  methylene  blue  may  be  tried.  As  prophy- 
lactic measures  mosquitoes  should  be  destroyed  as  for  malaria, 
houses  screened,  and  water  filtered  and  boiled. 

Trichocephalus  dispar  requires  no  special  treatment. 

DRACONTIASIS  (GUINEA-WORM  DISEASE) 

Dracontiasis  is  the  term  applied  to  the  group  of  morbid  phenomena 
induced  by  the  presence  in  the  body  of  the  Filaria  or  Dracunculus 
medinensis.  The  female  parasite  alone  is  known.  It  enters  the 
system  through  the  stomach  and  migrates  to  the  subcutaneous 
connective  tissue  especially  of  the  lower  extremities  near  the  ankles, 
where  it  matures.  After  a  period  of  quiescence  it  excites  suppuration 
and  abscess  formation.  The  embryos  are  discharged  and  in  some 
manner  find  their  way  to  sources  of  water.  Here  they  are  probably 
taken  up  by  a  small  crustacean  (cyclops) .  Infected  drinking  water 
is  the  cause  of  the  disease  in  man.  No  race,  age,  or  sex  is  exempt. 
The  treatment  consists  in  opening  the  abscesses  and  removing  the 
worm  and  its  embryos  intact.  Injections  of  bichloride  of  mercury 
(i  to  1000)  are  of  value. 

DISEASES  OF  THE  LIVER 

Preliminary  Considerations. — Normally,  the  greater  portion  of 
the  liver  is  situated  in  the  right  upper  quadrant  of  the  abdomen, 
a  small  portion  extending  over  the  median  line  into  the  left  upper 
quadrant.  Percussion  over  the  area  occupied  by  the  liver  yields  a 
dull  note.  Absolute  liver  dullness  extends  in  the  median  line  from  the 
lower  border  of  cardiac  dullness  to  midway  between,  the  ensiform 
appendix  and  the  umbiUcus;  in  the  mammillary  line  from  the  upper 
border  of  the  sixth  rib  to  the  costal  margin;  in  the  axillary  line  from 


DISEASES    OF    THE    LIVER 


283 


the  eighth  to  the  eleventh  rib ;  and  posteriorly  from  the  tenth  to  the 
eleventh  rib.  This  is  graphically  shown  in  a  table  by  Hutchinson  and 
Rainy,  as  follows: 


Middle  line 

Mammillary        Midaxillary           Scapular 
line                       line                      line 

Deep  dullness. 

Upper     1 

limit.     Superficial 
dullness. 

Blend  with 
heart       dull- 
ness. 

Hand's- 
breadth 
below      base 
of  xiphoid. 

Fourth  space. 

Seventh 
space. 

Ninth    space. 

Sixth  rib. 

Eighth  rib. 

Tenth  rib. 

Lower  limit. 

Costal      mar- 
gin or  some- 
what    above 
or  below  it. 

Tenth 
space. 

Blends      with 
kidney    dull- 
ness. 

The  situation  of  the  liver  may  be  altered  as  the  result  of  transposi- 
tion of  the  viscera,  tight  lacing,  ascites,  abdominal  tumors,  pleurisy, 
or  emphysema.  Varying  degrees  of  displacement  may  be  encoun- 
tered. Floating  liver  is  a  rare  condition  of  this  kind,  in  which  relaxa- 
tion and  elongation  of  its  ligaments  permit  it  to  fall  from  its  normal 
position,  especially  when  the  erect  posture  is  assumed.  Tight  lacing 
and  pendulous  abdomen  are  given  as  causes.  The  organ  is  recognized 
in  its  new  position  by  its  shape  and  dullness  and  its  absence  from  the 
normal  situation  aids  in  confirming  the  diagnosis. 

The  principal  abnormality  in  shape  of  the  liver  is  that  known  as 
^' corset-liver^^  or  the  "laced-of^'  liver  which  results  from  the  wearing 
of  tight  waist  bands  and  corsets.  It  is  characterized  by  division  of 
the  right  lobe  into  two  almost  equal  parts  by  a  transverse  furrow. 
The  connection  between  the  two  parts  is  in  very  rare  cases  reduced  to 
a  fibrous  band.  The  affection  is  most  common  in  women  and  seems 
to  favor  cholelithiasis.  There  are  no  symptoms,  as  a  rule,  and  the 
possibility  of  this  condition  should  be  considered  in  examining  for 
floating  kidney,  and  other  visceral  displacements. 

In  the  physical  examination  of  the  liver  it  should  be  remembered 
that  normally  the  edge  of  the  liver  is  seldom  felt  by  the  examining 
fingers  except  in  thin  and  emaciated  subjects  and  in  young  children. 
It  becomes  palpable  when  enlarged  or  displaced  from  any  cause. 
Irregularities  of  the  surface  of  the  liver  suggest  the  possibility  of  cancer, 
syphilis,  abscesses,  or  hydatids.  Alterations  in  the  consistency  of 
the  hepatic  structure  are  indicative  of  certain  changes,  thus  in  cancer, 
congestion,  hypertrophic  cirrhosis,  and  amyloid  infiltration,  the  liver 


284  CONGESTION    OF    THE    LIVER 

is  more  dense ;  while  in  abscesses  and  hydatid  cysts  the  consistency  is 
less,  particularly  in  the  diseased  area.  If  in  the  examination  tender- 
ness is  elicited,  it  points  to  the  presence  of  congestion,  inflammation, 
abscess  formation,  or  cancer.  Pulsation  is  occasionally  encountered 
and  is  nearly  always  due  to  passive  congestion  following  tricuspid 
regurgitation,  but  it  may  also  be  due  to  aneurysm  or  a  tumor  in 
close  proximity  to  the  abdominal  aorta  which  transmits  its  pulsation. 
The  size  of  the  liver  may  give  an  indication  of  the  character  of  the 
affection  in  many  instances;  thus  hypertrophic  cirrhosis,  congestion, 
cancer  when  diffuse,  and  fatty  and  amyloid  conditions  produce  a  more 
or  less  uniform  enlargement  of  the  organ;  in  cancer,  gumma,  abscess, 
hydatid  cysts,  and  similar  affections  the  enlargement  is  somewhat 
nodular  in  character;  and  in  atrophic  and  degenerative  conditions 
the  organ  undergoes  diminution  in  size.  An  apparent  enlargement 
may  occur  when  the  liver  dullness  is  increased  by  any  pulmonary 
condition  that  displaces  the  organ  downward,  and  an  apparent 
diminution  may  be  observed  when  the  liver  dullness  is  obscured  by 
tympanites  from  any  cause,  or  by  pulmonary  or  subcutaneous 
emphysema. 

CONGESTION  OF  THE  LIVER 

Synonyms. — Torpid  liver;  biliousness. 

Definition. — An  abnormal  fullness  of  the  vessels  of  the  liver,  with 
consequent  enlargement  of  that  organ;  it  is  termed  active  when  ar- 
terial; passive  when  venous.  The  condition  is  characterized  by  tor- 
pidity of  the  digestive  and  mental  functions,  and  slight  jaundice. 

Causes. — Active  congestion;  heat,  atmospheric  or  artificial;  habitual 
constipation;  malaria;  excesses  in  eating  and  drinking;  alcoholic 
or  malt  Hquors.  In  females,  an  arrested  menstrual  epoch  may  give 
rise  to  an  attack. 

Passive  congestion;  cardiac  and  pulmonary  diseases. 

Pathological  Anatomy. — The  liver  is  enlarged  in  all  directions,  and 
is  abnormally  full  of  blood.  Cases  due  to  obstructive  diseases  of  the 
heart  or  lungs  present  the  so-called  ''nutmeg  liver"  appearance.  At 
the  center  of  each  lobule  the  dilated  radicle  of  the  hepatic  vein,  en- 
larged and  congested,  may  be  discerned,  while  the  neighboring  parts 
of  the  lobule  are  pale,  the  radicles  of  the  portal  vein  containing  less 
blood.  Long-continued  congestion  estabHshes  atrophic  degeneration 
or  cyanotic  induration  of  the  organ ;  the  decrease  in  size  is  confounded 


CONGESTION    OF   THE    LIVER  285 

with  the  condition  of  cirrhosis;  but  the  ''atrophic  liver"  is  smooth, 
while  the  ''cirrhotic  liver"  is  nodulated. 

S3ntnptoms. — Acute  congestion  begins  with  malaise,  aching  of  the 
limbs,  feverishness,  headache,  depression  of  spirits,  coated  tongue, 
anorexia,  nausea,  and  sometimes  vomiting.  Constipation  and  flatu- 
lence are  present,  and  there  is  a  feeling  of  fullness,  weight,  and 
soreness  in  the  hepatic  region  with  dull  pain  extending  to  the  right 
shoulder.  The  liver  is  uniformly  enlarged  and  tender.  The  com- 
plexion is  muddy  and  there  may  be  slight  jaundice.  The  attack 
usually  lasts  about  a  week. 

Passive  congestion  is  characterized  by  similar  symptoms  but  of  less 
severity.  The  onset  is  gradual  and  gastrointestinal  catarrh  is  com- 
mon. In  addition,  there  are  the  symptoms  of  the  causal  heart  or 
lung  disease. 

Prognosis. — The  acute  attacks  end  favorably,  but  if  there  is  a  con- 
stant repetition  of  them  atrophic  degeneration  is  the  usual  result. 
Passive  congestion  is  dependent  entirely  upon  the  severity  of  its 
cause  for  its  prognosis.  In  many  cases  atrophic  degeneration  or 
cyanotic  induration  follows. 

Treatment. — In  acute  attacks  induced  by  dietetic  indiscretions  the 
following  mixture  should  be  given : 

I^.     Sodii  bicarb gr.  v  0.3  gm. 

Pulv.  ipecac gr.  ss  o .  03  gm. 

Hydrargyri  chloridi  mit gr.  iij  to  v  0.2  to  0.3  gm. 

M.  S. — To  be  taken  at  one  dose  and  followed  in  about  two 
hours  by  a  saline  cathartic,  or  by  sodium  phosphate,  5j  (4  gni-)- 

After  free  purgation  has  been  brought  about  the  following  should 
be  administered: 

I^.     Acid,  nitro-hydrochloric.  dil lUx     o .  6  c.c. 

Elix.  taraxaci  comp f  5ij    8.0  c.c. 

M.  S. — To  be  taken  about  a  half -hour  before  meals. 

Malarial  cases  should  receive  appropriate  doses  of  quinine  and  pa- 
tients with  chronic  heart  or  lung  disease  should  be  treated  according 
to  the  necessities  of  the  individual  case.  In  all  chronic  cases,  rest, 
liquid  diet,  free  purgation  with  salines  or  cholagogues,  and  cupping 
will  be  of  benefit.  Strychnine  sulphate  and  sodium  arsenate  may 
also    be  employed  internally. 

In  acute  attacks,  hot  applications  and  sinapisms  may  be  applied 
over  the  region  of  the  liver. 


286  ABSCESS    OF   THE   LIVER 


ABSCESS  OF  THE  LIVER 

Synonyms. — Suppurative  hepatitis;  parenchymatous  hepatitis; 
acute  hepatitis. 

Definition. — A  diffused  or  circumscribed  inflammation  of  the  hepatic 
cells,  resulting  in  suppuration,  the  abscesses  being  sometimes  single, 
at  times  multiple;  characterized  by  irregular  febrile  attacks,  hepatic 
tenderness,  and  symptoms  of  deranged  gastrointestinal  and  hepatic 
functions. 

Causes. — The  exciting  causes  are  pathogenic  bacteria,  particularly 
ameba  coli,  colon  bacillus,  staphylococcus,  and  streptococcus.  In 
most  cases  the  portal  circulation  is  the  transmitting  medium  of  the 
infection.  In  amebic  dysentery,  the  microorganisms  reach  the  liver 
and  produce  suppuration  through  this  system  of  vessels.  Infectious 
thrombi  and  emboli  from  any  area  drained  by  the  portal  system,  when 
carried  to  the  liver  give  rise  to  purulent  inflammation  and  abscesses. 
This  is  sometimes  seen  in  gastric  and  duodenal  iilcers,  purulent  appen- 
dicitis, and  similar  affections  of  the  digestive  tract.  Infectious  em- 
boli from  ulcerative  endocarditis,  pyemia,  pulmonic  conditions, 
osteomyelitis,  injuries,  etc.,  may  reach  the  liver  through  the  hepatic 
artery,  and  abscesses  result.  In  the  new-born  infant,  umbilical 
phlebitis  may  terminate  in  hepatic  suppuration.  Suppuration  of  an 
hydatid  cyst,  suppuration  following  impacted  gall-stones,  and  trauma- 
tism may  also  be  causes  of  liver  abscesses.  Dysentery  is  the  most 
common  of  all  the  etiological  factors. 

Pathological  Anatomy. — If  the  condition  is  the  result  of  dysentery 
or  injury  there  will  be,  as  a  rule,  but  one  abscess  and  it  will  in  m^ost 
cases  occupy  the  right  lobe.  In  those  cases  due  to  pyemia  and  simi- 
lar conditions,  there  will  be  multiple  abscesses.  '  As  the  abscess  pro- 
gresses it  tends  to  rupture  and  may  burst  into  the  peritoneum,  in- 
testines, stomach,  gall-bladder,  hepatic  duct  or  vein,  pleura,  or  lungs, 
or  it  may  perforate  the  abdominal  wall  and  discharge  externally. 
After  the  pus  has  been  evacuated  cicatrization  occurs.  Sometimes 
the  pus  is  absorbed  and  the  abscess  replaced  by  a  scar,  but  more 
frequently  absorption  of  the  pus  is  attended  by  septicemia. 

Symptoms. — The  constitutional  manifestations  include  irregular 
interniittent  fever  or  remittent  fever,  chills,  sweats,  obstinate  vomit- 
ing, gastrointestinal  disorders,  constipation,  light-colored  stools, 
slight  jaundice,  irritability  of  the  nervous  system,  melancholia, 
anemia,  leukocytosis,  and  in  marked  cases  typhoid  symptoms. 


ACUTE  YELLOW  ATROPHY  287 

The  local  symptoms  consist  of  hepatic  enlargement  upward,  cir- 
cumscribed bulging,  pain  extending  to  the  right  shoulder,  tenderness, 
and  fluctuation.  When  the  abscess  tends  to  burst  externally,  the  area 
over  it  becomes  hot,  red,  tender,  swollen,  and  edematous. 

Diagnosis. — In  doubtful  cases  the  aspirator  may  be  employed. 
Cancer  is  distinguished  by  its  longer  course,  history,  nodular  enlarge- 
ment of  the  liver,  emaciation,  cachexia,  and  the  absence  of  septic 
phenomena. 

Intermittent  fever  is  characterized  by  definite  paroxysms,  enlarge- 
ment of  the  spleen,  and  the  presence  of  malarial  organisms  in  the 
blood. 

Hepatic  intermittent  fever  differs  from  hepatic  abscess  in  its  history 
of  several  attacks,  its  less  serious  course,  biliary  colic,  and  obstinate 
jaundice. 

Pleural  effusion  on  the  right  side  may  be  differentiated  from  hepatic 
abscess  by  diminished  fremitus  and  vocal  resonance,  and  bronchial 
breathing  if  the  lung  is  compressed. 

Hydatid  cyst  differs  from  abscess  in  its  slower  course,  the  absence 
of  septic  symptoms,  and  the  withdrawal  of  clear  fluid  and  hooklets 
on  aspiration.  In  the  presence  of  suppuration,  the  finding  of  the 
hooklets  is  diagnostic. 

Prognosis. — In  traumatic  and  amebic  abscesses  when  the  pus  can 
be  evacuated  early,  favorable  termination  may  occur,  but  in  pyemic 
and  other  forms  the  affection  is  fatal. 

Treatment. — Palliative  measures  such  as  the  administration  of 
nutritious  food,  iron,  quinine,  strychnine,  and  alcohol  should  be 
prescribed.  When  the  abscess  is  single  and  can  be  definitely  located 
it  should  be  evacuated  and  drained. 

ACUTE  YELLOW  ATROPHY 

S5monyms. — Parenchymatous  hepatitis;  malignant  jaundice;  hem- 
orrhagic icterus. 

Definition. — An  acute,  diffused,  or  general  inflammation  of  the 
hepatic  cells,  resulting  in  their  complete  disintegration;  characterized 
by  diminution  in  the  size  of  the  liver,  deep  jaundice,  hemorrhages, 
and  profound  disturbance  of  the  nervous  system,  terminating  in 
death,  usually  within  one  week. 

Causes. — The  cause  is  unknown.  The  affection  is  apparently 
due  to  the  presence  of  some  very  toxic  agent  in  the  blood.     It  is 


288  ACtTTE  YELLOW  ATROPHY 

very  rare  and  occurs  with  greatest  frequency  in  young  pregnant 
women  from  the  third  to  the  sixth  month  of  gestation.  Among  the 
other  causes  may  be  mentioned  infectious  diseases,  alcoholic  and 
venereal  excesses,  syphilis,  mental  excitement,  and  poisoning  by 
phosphorus,  arsenic,  or  antimony.  Bacteria  have  been  found  in 
the  organ  after  death.  Autodigestion  has  also  been  suggested  as  the 
cause. 

Pathological  Anatomy. — In  the  early  stage  there  is  hyperemia 
of  the  hepatic  cells  with  a  grayish  exudation  between  the  lobules. 
The  organ  becomes  soft  and  friable  and  of  a  red  or  dull  yellow  color; 
the  liver  is  yellow  when  the  cells  are  left  and  are  bile-stained,  and  red 
when  the  cells  are  destroyed  and  their  places  taken  by  dilated  capil- 
laries and  hemorrhages.  The  cells  rapidly  disappear,  only  capillaries 
and  supporting  tissue  being  left,  and  the  liver  is  therefore  reduced  in 
size  and  weight .  Areas  of  necrosis  are  found  in  the  center  of  the  lobules 
as  in  the  toxic  vomiting  of  pregnancy.  Hemorrhagic  extravasations 
are  present.  The  peritoneal  covering  of  the  liver  is  loose  and  thrown 
into  folds.  The  spleen,  kidneys,  heart,  and  muscles  undergo  par- 
enchymatous degeneration.  The  urine  is  loaded  with  bile  pig- 
ment and  the  blood  contains  a  large  amount  of  urea  and  leucin. 

Symptoms. — The  early  stage  of  this  condition  resembles  an  attack 
of  acute  catarrhal  jaundice,  being  attended  at  first  by  gastrointestinal 
catarrh,  coated  tongue,  nausea,  tenderness  over  the  epigastrium, 
headache,  quickened  pulse,  slight  fever,  and  slight  jaundice.  Soon 
the  jaundice  deepens;  the  pulse  becomes  slow;  the  headache  increases; 
and  there  is  persistent  insomnia.  Within  a  very  short  period  appear 
delirium,  fever,  rapid  pulse,  abdominal  pain,  "coffee  grounds"  vomit, 
tarry  stools,  hemorrhages  from  the  mucous  membranes  and  into  the 
skin,  convulsions,  drowsiness,  coma,  and  death.  The  affection  seldom 
lasts  more  than  a  week  but  in  some  cases  is  prolonged  to  two  or  three 
weeks. 

The  liver  diminishes  rapidly  in  size  as  may  be  shown  by  palpation 
and  percussion  and  there  is  pitting  on  pressure  in  the  epigastric  region. 
The  spleen  is  enlarged;  obstinate  vomiting,  intense  jaundice,  and  hem- 
orrhages may  occur.  The  urine  is  scanty,  of  high  specific  gravity,  and 
contains  albumin,  bile,  bile-stained  fatty  casts,  renal  epithelium, 
leucin  spheres,  tyrosin  needles,  and  aromatic  oxyacids.  Urea  is 
diminished  and  may  be  absent. 

Prognosis. — The  disease  always  terminates  fatally.  Apparent 
recoveries  nearly  always  imply  erroneous  diagnosis. 


CIRRHOSIS    OF    THE    LIVER  289 

Treatment. — The  treatment  consists  entirely  in  combating  the 
symptoms  as  they  arise. 

CIRRHOSIS  OF  THE  LIVER 

Synonyms. — Interstitial  hepatitis;  hobnailed  liver;  gin-drinker's 
liver. 

Definition. — An  inflammation  of  the  intervening  connective  tissue 
of  the  liver,  chronic  in  its  progress,  resulting  in  an  induration  or 
hardening  of  the  organ,  and  an  atrophy  of  the  secreting  cells;  charac- 
terized by  gastrointestinal  catarrh,  emaciation,  slight  jaundice,  and 
ascites. 

Causes. — The  prolonged  use  of  alcoholic  stimulants,  gin,  whiskey, 
beer,  or  porter  is  perhaps  the  most  common  cause.  It  may  also  be  due 
to  malaria,  syphilis,  passive  congestion,  and  irritation  of  the  gall- 
ducts.  The  cause  may  be  undiscoverable.  It  usually  occurs  in  men 
past  thirty-five  years  of  age.  The  uric  acid  diathesis  may  be  a 
causal  factor. 

Pathological  Anatomy. — Two  varieties  of  the  affection  are  recog- 
nized, atrophic  cirrhosis  and  hypertrophic  cirrhosis. 

Atrophic  cirrhosis  begins  with  hyperemia  of  the  connective  tissue 
(Glisson's  capsule)  and  enlargement  of  the  liver  results  from  the 
development  of  brownish-red  connective- tissue  elements.  The 
connective  tissue  surrounding  the  interlobular  veins  is  increased  and 
encloses  several  lobules  at  a  time — hence  the  name — multilobular  cir- 
rhosis, often  applied  to  this  form  of  the  disease.  The  hypertrophied 
connective  tissue  presses  upon  the  hepatic  cells  causing  them  to  un- 
dergo fatty  degeneration.  As  this  process  advances  the  organ  becomes 
reduced  in  size  and  more  dense,  and  its  surface  is  covered  with  numer- 
ous small  nodules  ("hobnails").  The  hepatic  and  portal  circulation 
is  obstructed  from  obliteration  of  their  respective  radicles.  The 
changes  in  the  hepatic  structure  interfere  with  the  venous  circulation 
of  all  the  abdominal  viscera,  resulting  in  venous  congestion  of  the 
stomach,  pancreas,  intestines,  and  peritoneum,  and  enlargement  of 
the  abdominal  veins.  The  hepatic  peritoneum  is  thickened  and 
opaque,  and  adhesions  are  formed  between  the  liver  and  diaphragm, 
gall-bladder  and  stomach.  On  section  of  the  liver,  firm  fibrous 
tissue  is  found  in  abundance  distributed  between  the  lobules. 

Hypertrophic  cirrhosis  occurs  in  younger  individuals  than  the 
preceding  and  does  not  seem  to  be  dependent  upon  alcohol  for  its 
production.     The  organ  is  yellowish  in  color  and  remains  enormously 

19 


290  CIRRHOSIS    OF   THE   LIVER 

enlarged  throughout  its  entire  course.  The  newly  formed  connective 
tissue  shows  very  little  tendency  toward  contraction  or  toward  com- 
pression of  any  of  the  branches  of  the  portal  vein.  The  connective 
tissue  is  developed  to  a  greater  extent  within  the  lobules  and  thus 
produces  obstruction  of  the  biliary  channels  and  consequent  jaundice. 
By  some  observers  it  is  claimed  that  there  is  a  new  formation  of  bili- 
ary capillaries  and  a  proliferation  of  the  liver  cells. 

The  main  thing  to  remember  is  that  cirrhosis  is  characterized  by  an 
increased  growth  of  fibrous  tissue  in  the  capsule  of  Glisson  and  of 
connective  tissue  in  the  hver  substance;  by  portal  obstruction;  by 
increased  blood  pressure  in  the  hepatic  arteries;  and  later  by  obstruc- 
tion of  the  biliary  ducts,  and  obliteration  of  the  liver  cells. 

Symptoms. — All  the  manifestations  of  hepatic  cirrhosis  are  due  to 
the  obstruction  to  the  portal  circulation  which  it  induces.  Persistent 
gastrointestinal  catarrh  attended  by  anorexia,  fetor  of  the  breath, 
nausea,  epigastric  distention  and  distress,  flatulence,  and  constipation 
are  present.  When  accompanied  by  attacks  of  jaundice  in  a  drinking 
man,  the  early  stage  of  cirrhosis  of  the  liver  should  be  suspected.  As 
the  condition  progresses  and  the  obstruction  becomes  more  marked, 
hemorrhages  from  the  nose,  esophagus,  stomach,  or  intestine,  hemor- 
rhoids, dilatation  of  the  superficial  abdominal  veins  forming  the 
^^  caput  meduscB,'^  ascites,  enlargement  of  the  spleen,  and  swelling  and 
edema  of  the  feet  occur.  The  condition  is  afebrile,  and  emaciation, 
localized  abdominal  pain,  and  sometimes  jaundice  are  present. 

In  atrophic  cirrhosis  the  hver  dullness  is  enlarged  at  first,  but  later 
becomes  markedly  lessened.  Splenic  dullness  is  enlarged.  The  skin 
has  a  muddy  appearance  and  there  is  gradual  emaciation.  The 
symptoms  continue  from  two  to  four  years,  terminating  fatally  in 
about  one  year  after  the  dropsy  makes  its  appearance.  The  urine  is 
scanty,  high-colored,  of  increased  density,  and  is  loaded  with  urates. 
The  quantity  of  urea  is  diminished,  and  blood  and  bile  pigment  may 
be  present.  The  ending  of  the  affection  is  marked  by  drowsiness, 
delirium,  convulsions,  and  coma,  death  resulting  from  toxemia, 
exhaustion,  hemorrhage,  or  similar  conditions. 

In  hypertrophic  cirrhosis,  jaundice  is  an  early  and  persistent  symp- 
tom. Congestion  of  the  digestive  tract,  enlargement  of  the  spleen, 
hemorrhoids,  and  ascites  are  absent  or  present  only  in  mild  degrees. 
The  liver  is  permanently  enlarged,  smooth,  tender,  and  the  seat  of 
paroxysms  of  pain.  The  urine  is  bile-stained  and  the  percentage  of 
urea  is  normal.     Blood  is  absent.     The  feces  may  be  devoid  of  bile 


CIRRHOSIS    OF    THE    LIVER  29 1 

pigment  or  may  be  normal.  The  red  blood  cells  are  diminished  about 
one-half,  and  there  is  a  relative  increase  in  the  leukocytes.  This 
form  of  the  affection  is  more  rapid  than  the  preceding,  terminating 
with  acute  toxemic  symptoms  in  death,  usually  in  one  or  two  years. 
Diagnosis. — The  characteristics  of  hepatic  cirrhosis  are  the  history, 
area  of  liver  dullness,  symptoms  of  portal  obstruction,  jaundice,  and 
the  course  and  termination.  The  distinction  between  the  two  varie- 
ties is  well  given  by  Thayer  in  the  following  table,  which  may  be 
useful  to  students: 


Hypertrophic  cirrhosis 


Atrophic  cirrhosis 


Synonyms.     Hanot's;  hypertrophic;  unilobu-   Laennec's;      atrophic;      multilobular; 


lar;  hepatogenous;  biliary 
Jaundice.     Early    and    marked,     bile     often 

absent  from  feces. 

Ascites.     Late  and  unimportant 

Spleen.     Enlarged  early  and  markedly 

Alimentary  hemorrhage,  piles.     Not  common. 

Liver.     Large,  smooth,  mottled,  green 

New  fibrous  tissue.     In  fine  lines  and  strands 
■  between  acini  and  cells,  involving  all  parts 

equally. 


hematogenous;  hobnail  liver. 
Late  and  slight,  bile  usually  present. 

May  be  early;  often  enormous. 

Late  and  less. 

Common. 

Small,  rough,  pale  or  yellow. 

In  broad  bands,  making  prominent 
islands  in  which  the  single  acinus 
may  appear  nearly  normal;  distrib- 
uted irregularly. 


Atrophy  of  the  liver,  or  the  nutmeg  liver^  is  almost  always  confounded 
with  cirrhosis;  the  former  occurs  most  commonly  with  obstructive 
diseases  of  the  heart  and  lungs,  and  the  surface  of  the  organ  is  not 
nodulated,  nor  is  there  a  history  of  alcoholism. 

Cancer  and  tubercle  of  the  peritoneum  have  many  symptoms  akin  to 
cirrhosis.  The  points  of  differentiation  are,  great  tenderness  over 
abdomen,  rapidly  developed  ascites,  rapid  decline  in  strength  and 
flesh,  absence  of  jaundice,  absence  of  long-continued  dyspepsia, 
absence  of  hepatic  changes  in  percussion,  and  the  presence  of  tubercle 
or  cancer  deposits  in  other  organs.     (See  table  on  page  295.) 

Prognosis. — The  outlook  is  unfavorable  and  while  many  cases  have 
a  very  long  course,  the  disease  ultimately  has  a  fatal  termination. 

Treatment. — The  diet  should  be  restricted  to  milk  and  similar 
unirritating  food.  Fatty  and  saccharine  substances  should  be  elimi- 
nated. Alcoholic  individuals  should  be  advised  to  cease  drinking. 
The  gastrointestinal  catarrh  should  receive  symptomatic  treatment. 
Bichloride  of  mercury,  gr.  y^o  to  3^2  (0.002  gm.),  gold  and  sodium 
chloride,  gr.  >^o  (0.003  gi^^Oj  sodium  phosphate,  5ss  to  j  (2  to  4  gm.), 
and  potassium  iodide,  gr.  x  (0.6  gm.),  three  times  daily,  are  highly 


292  AMYLOID   LIVER 

recommended.  The  portal  congestion  is  best  relieved  by  salines, 
such  as  Hunyadi,  Saratoga,  Friedrich'Shall,  or  Carlsbad  waters,  and 
Rochelle  or  Epsom  salts.  The  abdominal  dropsy  or  ascites  will  re- 
quire the  administration  of  saline  purgatives  and  diuretics.  A  half 
ounce  of  a  concentrated  solution  of  magnesium  sulphate  taken  dail}' 
before  breakfast  is  of  value,  as  is  also  the  pill  containing  i  gr.  each  of 
calomel,  digitalis,  and  squill  when  given  after  each  meal.  Acetate  of 
potassium  may  also  be  used.  Tapping  is  necessary  when  these  meas- 
ures fail. 

Surgical  treatment,  with  a  view  to  establishing  an  anastomosis  be- 
tween the  portal  and  systemic  circulation,  has  been  employed;  but  it 
should  never  be  considered  in  the  presence  of  complicating  renal  or 
cardiac  disease. 

AMYLOID  LIVER 

Synonyms. — Waxy  liver;  lardaceous  Hver;  albuminoid  liver. 

Definition. — A  peculiar  infiltration  into,  or  a  degeneration  of,  the 
structure  of  the  liver,  from  the  deposit  of  an  albuminoid  material 
which  has  been  termed  amyloid,  from  its  superficial  resemblance  to 
starch  granules. 

Causes. — The  principal  cause  is  prolonged  suppuration,  especially 
of  bones.  It  is  seen  in  coxalgia,  pulmonary  tuberculosis,  syphilis, 
rachitis,  cancer,  leukemia,  and  certain  infectious  diseases. 

Pathological  Anatomy. — The  Hver  is  uniformly  enlarged  and  its  sur- 
face presents  a  pale,  gHstening  appearance.  It  has  a  doughy  consist- 
ency, and  its  edges  are  blunt.  The  surface  of  a  cut  section  is  whitish, 
anemic,  and  homogeneous.  The  deposit  begins  in  the  arterioles  and 
capillaries  and  spreads  to  the  fibrous  tissue  and  parenchyma.  The 
other  viscera  become  ultimately  affected  by  the  degenerative  change. 

The  reaction  with  iodine  and  sulphuric  acid  affords  a  certain  test 
for  the  amyloid  or  albuminoid  deposits.  After  further  cleansing, 
brush  over  the  parts  a  solution  of  iodine  with  iodide  of  potassium  in 
water,  when  they  will  assume  a  mahogany  color,  and  if  diluted  sul- 
^phuric  acid  be  added,  a  violet  or  bluish  tint  is  produced. 

It  may  also  be  detected  by  adding  a  i  per  cent,  solution  of  anilin 
violet,  which  strikes  a  pink  color  with  the  amyloid  material,  while  the 
unaffected  tissues  are  plain  blue. 

Symptoms. — There  are  no  characteristic  manifestations,  except 
the  enlargement  of  the  liver.  Hepatic  dullness  is  increased  and  there 
is  prominence  of  the  hepatic  area.     Pain  is  absent.     The  spleen  and 


HYDATID    CYST   OF   THE    LIVER  293 

kidneys  are  enlarged  and  the  urine  is  increased  in  amount,  pale, 
albuminous,  and  contains  amyloid  casts  when  the  kidneys  are  in- 
volved by  the  amyloid  change.  Disorders  of  digestion,  diarrhea, 
emaciation,  and  anemia  are  common.  Jaundice  and  ascites  are 
infrequent. 

Diagnosis. — Leukemia  is  also  characterized  by  uniform  enlarge- 
ment of  the  liver  and  spleen,  but  the  history,  the  examination  of  the 
blood,  and  the  presence  or  absence  of  amyloid  casts  in  the  urine  will 
aid  in  making  the  diagnosis. 

Prognosis. — The  progress  of  the  affection  may  be  retarded  and  the 
symptoms  relieved  if  the  underlying  cause  can  be  removed,  other- 
wise the  prognosis  is  unfavorable. 

Treatment. — The  focus  of  suppuration,  which  induces  the  condi- 
tion, should  receive  prompt  surgical  treatment.  Tonics,  such  as  iron, 
syrup  of  the  lactophosphate  of  calcium,  cod-liver  oil,  quinine,  etc., 
should  be  administered  over  a  long  period.  DaCosta  recommends 
ammonium  chloride,  gr.  x  to  xx  (0.6  to  1.3  gm.),  three  times  daily  for 
several  weeks,  after  which  it  is  replaced  by  the  syrup  of  the  iodide  of 
iron,  beginning  withTTtx  (0.6  c.c.)  and  increasing  it  to  5  j  (4  c.c),  for 
a  similar  period,  when  the  first  named  drug  is  again  employed. 

HYDATID  CYST  OF  THE  LIVER 

Synon3mi. — Echinococcus  of  the  liver. 

Definition. — A  cystic  condition  of  the  liver,  due  to  the  invasion  and 
subsequent  development  of  the  embryos  of  the  Tcenia  echinococcus, 
an  intestinal  parasite  found  in  dogs,  wolves,  and  jackals  in  Iceland, 
Australia,  and  portions  of  Europe.  It  is  rare  in  this  country,  but  in 
regions  where  the  relation  of  men  and  dogs  is  more  intimate,  it  is 
rather  common.  (See  page  275.)  The  ova  are  accidentally  ingested 
with  the  food  and  drink  of  men,  and  on  being  liberated  in  the 
stomach  and  intestines  the  larvae  find  their  way  into  the  portal  cir- 
culation, and  thus  reach  the  liver.  Here  they  become  lodged  and 
loosen  their  hooklets,  developing  into  a  cyst.  The  cyst  wall  has  two 
layers,  the  inner  of  which  is  the  germinal  layer  from  which  daughter 
cysts  are  developed.  The  attendant  irritation  gives  rise  to  the  forma- 
tion of  an  additional  capsule  of  connective  tissue.  The  contents  of  the 
cyst  include  a  clear  non- albuminous  fluid  of  low  specific  gravity  rich 
in  chlorides,  larvae,  hooklets  and  daughter  cysts.  The  cyst  grows 
slowly,  and  on  the  death  of  the  parasite  it  may  undergo  inspissation 
and  calcification  or  suppuration. 


294  SYPHILIS    OF   THE   LIVER 

Sjmiptoms. — Unless  the  cyst  is  large  there  are  no  symptoms  as  a 
rule.  The  liver  is  then  irregularly  enlarged  and  there  is  a  sense  of 
fullness  in  the  hepatic  region.  Fluctuation  may  be  detected  in  some 
cases.  If  the  cyst  is  near  the  surface,  the  placing  of  one  hand  over 
the  tumor  and  tapping  it  lightly  with  the  fingers  of  the  other  hand, 
will  elicit  a  vibrating  or  trembling  movement,  hydatid  thrill  or  frem- 
itus. Aspiration  should  always  be  performed,  as  the  presence  of  a 
few  hooklets  in  the  clear  fluid  withdrawn  is  diagnostic.  Jaundice, 
pain,  dyspnea,  fever,  and  pyemic  symptoms  may  occasionally  be 
present.  Suppuration  and  rupture  are  the  most  common  termina- 
tions, but  the  possibility  of  such  a  condition  remaining  quiescent, 
should  be  remembered. 

Diagnosis. — The  history,  slow  course,  smooth  elastic  fluctuating 
tumor,  without  fever  or  emaciation,  and  the  aspirated  fluid  and  hook- 
lets  will  distinguish  it  from  abscess,  cancer,  or  other  conditions  with 
which  it  may  be  confused. 

Prognosis. — In  the  absence  of  complications,  the  outlook  is  guard- 
edly favorable,  otherwise  it  is  extremely  serious. 

Treatment. — There  is  no  medicinal  treatment.  Aspiration  may  be 
performed,  or  the  cyst  may  be  treated  as  an  abscess. 

SYPHILIS  OF  THE  LIVER 

Syphilis  of  the  Hver  may  be  congenital  or  acquired.  The  congen- 
ital form  may  be  either  a  diffused  cellular  infiltration  which  produces 
at  first  enlargement  and  hardening,  and  later  atrophic  changes  and 
irregularities,  or  a  circumscribed  lesion,  a  gumma.  The  acquired 
variety  includes  diffuse  interstitial  hepatitis,  gumma,  amyloid  disease, 
endarteritis,  perihepatitis,  and  cicatrices. 

Symptoms. — Jaundice  in  the  course  of  syphihs  should  always  indi- 
cate subsequent  careful  attention  to  the  liver.  Frequently  the 
lesions  escape  detection  ante-mortem.  The  symptoms,  when 
present,  are  those  of  portal  obstruction  as  in  ordinary  cirrhosis. 

Diagnosis. — This  is  extremely  difficult  and  depends  largely  on  the 
history  and  the  results  of  the  therapeutic  test. 

Treatment. — Antisyphilitic  treatment  should  be  promptly  insti- 
tuted if  there  is  the  slightest  possibility  of  syphilis,  as  in  the  early 
cases  the  best  results  are  obtained. 

CARCINOMA  OF  THE  LIVER 

Synonjrm. — Hepatic  cancer. 

Definition. — A  peculiar  morbid  growth,  progressively  destroying 


CARCINOMA    OF    THE    LIVER 


295 


the  hepatic  tissue;  characterized  by  disorders  of  digestion,  anemia, 
emaciation,  jaundice,  and  ascites,  and  terminating  in  death  of  the 
patient. 

Causes. — It  may  arise  as  a  primary  growth,  but  it  is  more  often 
secondary  to  a  similar  affection  in  some  adjacent  or  remote  portion  of 
the  body.  It  usually  occurs  in  men  from  forty  to  sixty  years  of  age, 
and  seems  to  be  influenced  by  heredity,  traumatism,  and  various 
forms  of  irritation. 

Pathological  Anatomy. — In  most  cases  the  growth  is  secondary, 
and  is  an  admixture  of  medullary  and  scirrhus  cancer.  It  arises  from 
the  lodgement  of  cancerous  emboli  in  the  portal  capillaries.  These 
emboli  proliferate,  and  cause  portal  obstruction  and  infiltration  of  the 
liver  with  numerous  grayish-white  nodules,  which,  when  superficial, 
are  umbilicated.  The  liver  is  increased  in  size.  The  hepatic  cells 
atrophy,  and  the  branches  of  the  hepatic  artery  enlarge  and  permeate 
the  growth.  The  peritoneum  is  adherent,  cloudy,  and  thickened. 
Primary  cancer  of  the  liver  occurs  usually  as  a  solitary  growth,  but 
may  be  nodular  and  accompanied  by  cirrhosis. 

Symptoms. — The  development  of  hepatic  cancer  is  preceded  by  a 
history  of  dyspepsia,  flatulency,  and  constipation.  Abdominal 
distress,  weight,  and  pain,  increased  on  pressure,  are  noticed.  In  ad- 
dition there  are  jaundice,  ascites,  occasionally  intense  hemorrhages, 
emaciation,  feebleness,  anemia,  cold,  dry,  harsh  skin,  pinched  fea- 
tures, dejected  expression,  and  all  the  symptoms  of  cachexia.  Fever 
is  absent,  except  when  there  are  complications,  and  toward  the  ter- 
mination of  the  disease.  The  hepatic  dullness  is  increased,  and  the 
liver  is  indurated,  irregular,  nodulated,  and  painful  on  palpation. 

Diagnosis. — The  age,  sex,  history  of  primary  growth,  usually  in 
stomach,  cachexia,  pain  and  tenderness  on  palpation,  and  enlarge- 
ment and  nodulation  of  the  liver  are  the  distinguishing  features  of 
hepatic  cancer. 

Sometimes  the  diagnosis  between  carcinoma  and  cirrhosis  is  diffi- 
cult ;  the  following  table  (from  Wheeler  and  Jack)  may  help : 


Carcinoma 


Atrophic  cirrhosis 


r.  Progress:  Always  rapid 

2.  Liver:  Is   large,    and   the   nodular   character 
developed  from  the  first. 

3.  Pain:  Well  marked 

4.  Ascites:  Often  absent 

5.  Jaundice:  Often  a  marked  feature 


Often  slow. 

Enlarged  at  first,  then  smaller,  and 

more  nodular  as  atrophy  becomes 

more  marked. 

Not  marked. 

Usually  present. 

Not  till  late. 


296  SAkcOMA    OF    THE   LIVER 

Prognosis. — The  disease  always  terminates  in  death,  usually  within 
a  year  after  its  recognition. 

Treatment. — The  treatment  is  entirely  symptomatic.  Opium 
will  be  frequently  required  to  relieve  the  pain. 

SARCOMA  OF  THE  LIVER 

Sarcoma  of  the  liver  is  nearly  always  secondary,  arising,  usually,  as 
a  metastatic  growth  from  melanotic  sarcoma  of  the  eye.  It  is  multi- 
ple in  most  cases,  and  is  said  never  to  be  attended  by  ascites.  It  gives 
rise  to  irregular  enlargement  of  the  liver  and  a  host  of  symptoms 
common  to  all  chronic  hepatic  affections.  The  diagnosis  is  difficult 
and  the  condition  terminates  fatally. 

DISEASES    OF    THE    BILE  PASSAGES  AND 

GALL-BLADDER 

JAUNDICE 

S3nionym. — Icterus . 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  bile  ducts  and  of  the  duodenum;  characterized  by 
gastrointestinal  derangement,  yellowness  of  the  skin  and  sclera, 
itching  of  the  skin,  feverishness,  and  mental  depression. 

Causes. — Extension  of  gastrointestinal  inflammation,  such  as  fol- 
lows a  debauch,  excesses  in  eating  and  drinking,  and  exposure,  is  the 
most  common  cause.  Atmospheric  changes,  passive  congestion  of 
the  liver,  and  the  infectious  fevers,  such  as  pneumonia,  malaria, 
relapsing  fever,  etc.,  are  less  frequent  factors  in  its  production. 

Pathological  Anatomy. — The  mucous  membrane  of  one  or  more  of 
the  bile  ducts,  or  of  the  duodenum,  becomes  hyperemic,  swollen,  and 
thickened,  from  an  effusion  of  serum  into  the  submucous  tissue;  the 
result  of  this  condition  is  the  closure  of  the  biliary  passages,  thereby 
impeding  the  outward  flow  of  bile.  The  bile  in  the  hepatic  ducts 
being  retained  by  the  obstruction  results  in  a  staining  of  the  liver 
substance  and  an  absorption  of  bile,  with  its  appearance  in  the  blood. 

Symptoms. — The  affection  begins  with  epigastric  distress,  coated 
tongue,  impaired  appetite,  nausea,  with  perhaps  vomiting,  and  loose- 
ness of  the  bowels  and  slight  feverishness.  In  from  three  to  five  da^'^s 
the  eyes  become  yellow,  and  jaundice  gradually  appears  over  the 
whole  body;  the  feverishness  disappears,  the  skin  becomes  harsh,  dry, 
and  itchy,  the  bowels  constipated,  the  stools  whitish  or  clay-colored, 


JAUNDICE  297 

accompanied  with  much  flatus  and  colicky  pains;  the  urine  heavy  and 
dark,  loaded  with  urates  and  containing  biliary  elements.  A  few 
drops  of  the  urine  placed  on  a  whitish  surface,  and  a  drop  or  two  of 
nitric  acid  made  to  flow  against  it,  will  exhibit  the  following ''play  of 
colors:"  a  greenish  tint,  from  the  conversion  of  bilirubin  into  bili- 
verdin,  quickly  followed  by  blue,  violet,  red,  and  yellow,  or  brown. 
When  the  jaundice  is  complete,  the  surface  is  cold,  the  heart's  action 
slow,  the  mind  torpid  and  greatly  depressed,  and  there  is  pain  or 
tenderness  on  pressure  over  the  hepatic  region. 

The  symptoms  subside  within  a  few  days  after  the  jaundice  appears, 
but  the  depression,  discoloration,  and  condition  of  the  bowels  persist 
for  one  or  two  weeks. 

Diagnosis. — Catarrhal  jaundice  may  be  recognized  by  its  acute 
course,  the  history,  the  mild  symptoms,  the  age,  and  the  termination. 
Jaundice  is  readily  detected  by  examination  of  the  mucous  mem- 
branes of  the  eyes  and  mouth,  the  clay-colored  stools,  and  by  the 
reaction  of  the  urine  to  nitric  acid.  The  discoloration  of  the  skin 
alone  is  not  positive. 

When  jaundice  is  induced  by  obstruction  to  the  outflow  of  bile 
other  than  that  produced  by  inflammation,  such  as  arises  from  stric- 
ture of  the  common  duct,  tumors  of  the  abdominal  viscera,  foreign 
bodies  such  as  gall-stones  and  parasites,  fecal  accumulations,  spasms 
of  the  bile  ducts  due  to  emotion,  etc.,  the  symptoms  of  these  different 
affections  will  be  found  associated  with  the  icteroid  manifestations. 

Icterus  neonatorum  is  the  variety  that  occurs  in  children,  and  may 
be  due  to  a  patulous  ductus  venosus  which  allows  the  portal  blood, 
rich  in  bile,  to  enter  the  circulation;  or  to  some  morbid  condition  of 
the  liver  or  bile  duct  which  causes  insuperable  obstruction,  such  as 
septic  phlebitis  of  the  umbilical  vein,  or  congenital  syphilitic  hepatitis. 
In  the  first  variety,  recovery  is  the  rule  within  a  few  days,  to  a  week  or 
more,  but  in  the  second  the  termination  is  usually  fatal. 

N on- obstructive  or  hematogenous  jaundice  is  unassociated  with  in- 
flammatory changes  in  the  bile  ducts,  and  arises  from  disintegration 
of  the  blood  or  hemolysis.  It  may  be  caused  by  poisons,  such  as 
nitrobenzol,  chlorates,  snake  venom,  chloroform,  phosphorus,  etc., 
yellow  fever,  relapsing  fever,  bilious  fever,  pernicious  anemia,  pyemia, 
typhoid  fever,  acute  yellow  atrophy  of  the  liver,  and  similar  condi- 
tions. It  differs  from  catarrhal  jaundice  in  its  history,  the  absence  of 
clay-colored  stools,  and  less  staining  of  the  urine. 

Treatment. — The  patient  should  be  placed  at  rest  in  bed  and  the 


298  CHOLELITHIASIS 

diet  restricted  to  milk  and  lime-water,  broths,  eggs,  lean  meats,  etc., 
care  being  taken  to  eliminate  all  starchy,  fatty,  or  saccharine  sub- 
stances. Calomel,  gr.  3^  (0.016  gm.),  with  sodium  bicarbonate,  gr. 
iij  (0.2  gm.),  should  be  then  given  every  two  hours  until  twelve  doses 
are  taken,  followed  by  Hunyadi  water  or  the  following: 

I^.     Sodii  bicarb 5iv  15  gm. 

Tinct.  nucis  vom 5iv  15  c.c. 

Tinct.  capsici 3j  40.0. 

Tinct.  rhei 5ij  60  c.c. 

Inf.  gent.  comp.  .  .  .q.  s.  ad   gvj  ad  180  c.c. 

M.  S. — Dessertspoonful  every  four  or  five  hours,  in  water. 

Sodium  phosphate,  5j  (4  gni.),  may  also  be  given,  well  diluted, 
every  four  hours.  The  dry,  itching  skin  may  be  relieved  by  diaphore- 
sis, a  hot  bath  containing  potassium  carbonate  night  and  morning,  or 
a  weak  carbolic  acid  solution.  If  insomnia  is  present  potassium 
bromide,  gr.  xxx  (2  gm.),  may  be  administered.  Diuretics  are  indi- 
cated if  the  urine  continues  scanty,  preference  being  given  to  the  alka- 
line waters,  potassium  bitartrate  lemonade,  and  spirit  of  nitrous  ether, 
lUx  to  XX  (0.6  to  1.3  c.c).  In  cases  in  which  the  constipation  per- 
sists, aloes,  podophyllum,  colocynth,  and  other  cholagogues  should  be 
employed.  Irrigation  of  the  colon  once  daily  with  cold  water,  gradu- 
ally increasing  the  temperature,  is  often  very  effective.  During 
convalescence,  and  when  the  condition  tends  to  become  chronic,  the 
following  is  of  great  benefit: 

I^.     Strychninag  sulph gr.  ss  0.03  gm. 

Acid,  nitrohydrochloric  dil .    3iv  15 -O    c.c. 

Tinct.  gentian,  comp §ijss  75-0    c.c. 

M.  S. — Teaspoonful  after  meals,  well  diluted. 

CHOLELITHIASIS 

Synonyms. — Hepatic  calculi;  gall-stones;  hepatic  colic;  biliary 
calculi. 

Definition. — Concretions  originating  in  the  gall-bladder  or  biliary 
ducts,  derived  partly  or  entirely  from  the  constituents  of  bile.  Their 
presence  is  generally  unrecognized  until  one  or  more  attempt  to  pass 
along  the  ducts,  when  an  attack  of  hepatic  colic  is  produced. 

Causes. — Gall-stones  result  from  the  precipitation  of  the  crystal- 
lizable  cholesterin  and  its  combination  with  inspissated  mucus  in  the 


CHOLELITHIASIS  299 

gall-bladder  or  ducts.  Bacteria  (chiefly  the  bacillus  typhosus,  bacil- 
lus coli  communis,  and  staphylococcus)  are  causal  factors  in  that  they 
induce  inflammatory  changes  in  the  gall-bladder  in  consequence  of 
which  cholesterin  and  lime  salts  are  excreted  in  excess  and  deposited. 
The  affection  is  most  common  in  women  past  middle  life,  particu- 
larly in  those  who  have  abdominal  tumors  or  have  borne  a  number 
of  children.  Obesity,  sedentary  habits,  excesses  in  eating  (particu- 
larly of  saccharine  and  starchy  foods)  and  drinking,  tight  lacing, 
and  malignant  disease  of  the  stomach  and  liver  are  also  etiological 
factors. 

Pathology. — Biliary  calculi  vary  greatly  in  '  size  and  number ; 
several  hundred  have  been  found  in  the  gall-bladder.  As  a  rule,  the 
stone  is  brown  and  spherical,  oval,  or  polygonal.  The  shape  varies 
according  to  the  manner  in  which  the  calculi  are  packed  together 
during  their  formation.  Cholesterin  Is  the  chief  constituent,  but  bile 
pigment  and  lime  salts  may  also  be  present.  On  section,  the 
calculus  shows  the  manner  of  its  formation  by  the  concentrically 
arranged  layers  of  different  color.  Commonly  several  stones  exist, 
and  they  are  generally  found  in  the  gall-bladder  or  cystic  duct,  but 
may  very  rarely  be  found  in  the  liver  or  hepatic  duct. 

Sjmiptoms. — The  manifestations  of  biliary  calculi  vary  according 
to  the  course  of  the  affection.  While  they  remain  quiescent  in  the 
gall-bladder  they  may  occasion  but  very  little  discomfort  and  often 
remain  undetected  for  a  long  period.  Often  they  induce  expulsive 
efforts  of  the  gall-bladder  by  their  irritation,  and  may  be  pushed  on 
into  the  bowel,  into  the  cystic  duct,  or  into  the  common  duct.  This 
event  is  always  marked  by  hepatic  or  biliary  colic.  If  the  calculi  pass 
completely  into  the  bowel  and  are  not  too  large  they  may  appear  in 
the  stools,  more  often  they  slip  back  into  the  gall-bladder  and  the 
attack  subsides  to  recur  at  a  later  period.  If  they  pass  into  the  cystic 
or  common  duct,  and  neither  find  a  free  exit  nor  slip  back  into  the 
gall-bladder,  impaction,  perforation,  peritonitis,  suppurative  cholecys- 
titis, suppurative  angiocholitis,  and  hepatic  abscess  are  the  possible 
terminations.  Irritation  of  the  gall-bladder  by  gall-stones  is  beUeved 
by  some  observers  to  ultimately  induce  malignant  disease  of  the  biliary 
passages. 

Hepatic  colic  commences  suddenly  at  the  moment  a  calculus  passes 
from  the  gall-bladder  into  the  cystic  duct  with  piercing,  agonizing 
pain,  which  begins  over  the  gall-bladder  and  spreads  over  the  abdo- 
men to  the  chest  and  right  shoulder.     Tenderness  and  rigidity  are 


300  "     CHOLELITHIASIS 

present  over  the  gall-bladder  and  also  extend  over  the  abdomen. 
Nausea,  vomiting,  a  small  feeble  pulse,  cool  skin,  pale,  distorted, 
anxious  expression,  fainting,  spasmodic  trembling,  chills,  moderate 
fever,  and  sometimes  convulsions  accompany  the  attack.  The 
paroxysm  lasts  from  an  hour  to  two  or  more  days,  with  remissions 
until  the  calculus  reaches  the  duodenum,  when  the  pain  suddenly 
ceases.     When  the  stone  is  obstructed  in  its  passage  jaundice  results. 

Obstruction  of  the  cystic  duct  by  an  impacted  gall-stone  may  be 
followed  by  very  few  symptoms,  and  jaundice  is  absent.  It  may  give 
rise  to  dropsy  or  atrophy  of  the  gall-bladder  or  cholecystitis. 

Obstruction  of  the  common  duct  by  an  impacted  calculus  is  character- 
ized by  persistent  jaundice,  paroxysmal  pain,  and  ague-like  attacks  of 
chills,  intermittent  fever,  and  sweats.  Nausea  and  vomiting  may  be 
present,  and  there  may  be  enlargement  of  the  liver  and  spleen.  The 
stools  are  sometimes  bile-stained.  These  symptoms  may  continue 
for  months  or  years,  and  if  the  obstruction  is  not  reheved,  suppurative 
cholangitis,  perforation,  or  fibroid  induration,  dropsy,  or  atrophy  of 
the  gall-bladder  may  result. 

Diagnosis. — Hepatic  colic  may  be  mistaken  for  renal  colic,  but  in 
the  latter  affection  the  pain  begins  in  the  lumbar  region  and  follows 
the  line  of  the  ureters  into  the  genitals.  The  urine  is  bloody  and  may 
contain  the  stone.     Jaundice  is  absent. 

Intestinal  colic  is  attended  by  diffuse  abdominal  pain  and  disten- 
tion.    Flatulence  is  present  and  on  its  discharge  the  pain  is  reheved. 

Pleurisy  on  the  right  side  may  cause  some  confusion,  but  the  fric- 
tion sound  and  the  limitation  of  breathing  with  sharp  pain  on  inspira- 
tion will  aid  in  making  a  distinction. 

Appendicitis  is  characterized  in  most  cases  by  pain,  tenderness, 
and  rigidity  in  the  right  iliac  region,  and  by  the  absence  of  jaundice 
and  bile-stained  urine. 

Gastralgia  is  usually  attended  by  paroxysmal  pain  over  the  region 
of  the  stomach,  which  is  reheved  by  pressure  and  by  taking  food. 

Gastric  ulcer  may  be  accompanied  by  paroxysmal  pain,  under  which 
circumstances  it  is  usually  induced  by  eating,  and  in  addition 
localized  epigastric  tenderness,  hematemesis,  and  hyperacidity  are 
present. 

Pseudo-biliary  colic  may  resemble  this  affection  very  closely,  but  its 
occurrence  in  neurotic  women,  and  the  absence  of  calculi  in  the  stools, 
should  be  remembered  in  making  a  diagnosis. 

Prognosis. — Uncomplicated  cases  terminate  in  recovery  as  a  rule. 


ACUTE    INFECTIOUS    CHOLECYSTITIS  3OI 

The  occurrence  of  ulceration,  suppuration,  or  perforation,  is  of  grave 
significance. 

Treatment. — During  an  attack  of  hepatic  colic,  morphine  gr.  ^i 
and  atropine  gr.  ^50  should  be  administered  h3rpodermically  and 
must  often  be  repeated ;  and  hot  fomentations  should  be  applied  over 
the  region  of  the  liver  and  gall-bladder.  Chloroform  may  be  neces- 
sary in  some  cases  to  relieve  the  pain.  If  there  is  any  tendency 
toward  collapse,  a  hot  bath  and  diffusible  stimulants  should  be 
administered. 

Succeeding  the  attack  arid  during  the  intervals,  the  diet  should  be 
carefully  regulated,  eliminating  all  fatty  and  saccharine  substances 
and  the  patient  should  be  instructed  to  avoid  all  excesses  and  indulge 
moderately  in  exercise.  Water-drinking  should  be  encouraged,  and 
when  possible  the  saline  mineral  waters,  such  as  Carlsbad,  Vichy,  and 
Saratoga  waters  should  be  employed.  Sodium  bicarbonate  or  sodium 
phosphate,  5  j  (4  gm.),  may  be  administered  well  diluted  before  meals. 
When  constipation  tends  to  exist,  Rochelle  or  Epsom  salt  should  be 
given  regularly  to  overcome  it.  Ether,  turpentine,  and  sweet  oil 
have  been  recommended  as  solvents,  but  their  efficiency  in  this  re- 
spect is  very  doubtful.  The  succinate  of  sodium,  gr.  v  (0.32  gm.), 
administered  three  times  daily  is  accredited  with  beneficial  proper- 
ties in  preventing  recurrences. 

Surgical  intervention  is  the  only  treatment  of  lasting  value,  but  the 
patient  should  be  operated  on  as  soon  as  the  diagnosis  is  made.  If 
the  operation  is  undertaken  while  the  gall-stones  are  still  in  the  gall- 
bladder some  of  the  sequelae  (such  as  cancer,  and  perforation)  may  be 
avoided. 

ACUTE   INFECTIOUS   CHOLECYSTITIS 

Definition. — Acute  inflammation  of  the  gall-bladder. 

Causes. — The  affection  is  always  due  to  infection  by  pathogenic 
bacteria,  especially  the  colon  bacillus  and  typhoid  bacillus.  Occa- 
sionally the  pneumococcus,  staphylococcus,  and  streptococcus  are  the 
exciting  causes.  It  may  follow  irritation  from  gall-stones,  pneumonia, 
or  typhoid  fever. 

Pathological  Anatomy. — The  inflammation  may  be  of  varying 
grades.  In  mild  forms  the  exudate  is  mucoid  or  muco-purulent;  in 
the  more  severe  forms  it  is  purulent  and  the  inflammation  may 
proceed    to    ulceration,  perforation,   or  gangrene.     There  may  be 


302  ACUTE   PANCREATITIS 

adhesions  between  the  gall-bladder  and  colon  or  omentum.  In  rare 
instances  the  gall-bladder  may  be  distended  with  blood. 

Symptoms. — Pain  at  the  border  of  the  thorax  to  the  right  of  the 
median  line  is  invariably  present,  and  the  gall-bladder  is  enlarged  and 
tender.  Vomiting  is  common.  Fever  accompanies  the  condition 
and  jaundice  may  or  may  not  be  present.  In  the  presence  of  pus  the 
fever  becomes  irregular  and  attended  by  chills  and  sweats,  and  an 
examination  of  the  blood  will  show  leukocytosis. 

Diagnosis. — The  features  of  this  affection  that  serve  to  distinguish 
it  are  the  history,  the  preceding  affection  and  the  location  of  the  pain 
and  circumscribed  tenderness.  The  presence  of  a  tumor  in  the  region 
of  the  gall-bladder  is  confirmatory. 

Prognosis. — Many  mild  catarrhal  cases  undoubtedly  terminate  in 
recovery  without  being  recognized.  Suppurative  cases  are  unfavor- 
able and  tend  toward  a  fatal  termination.  Prompt  surgical  inter- 
vention offers  the  only  hope. 

Treatment. — The  symptoms  should  be  treated  as  they  arise  on 
general  therapeutic  principles.  A  skilled  surgeon  should  be  called  in 
as  soon  as  the  condition  is  detected. 


DISEASES  OF  THE  PANCREAS 

ACUTE  PANCREATITIS 

Definition. — An  acute  inflammation  of  the  pancreas  affecting, 
primarily,  the  fibrous  and  fatty  interstitial  tissue. 

Causes. — It  is  a  rare  disease,  but  is  most  common  in  males  after 
forty-five  years  of  age  and  may  result  from  gastrointestinal  disorders, 
impaction  of  gall-stones,  traumatism,  infectious  fevers,  and  local 
bacterial  infection. 

Pathological  Anatomy. — The  appearances  of  the  organ  differ  some- 
what according  as  the  termination  is  hemorrhagic,  gangrenous,  or 
suppurative. 

In  the  hemorrhagic  form  the  organ  is  enlarged  and  infiltrated  with 
blood  in  various  stages  of  decomposition,  and  scattered  between  these 
hemorrhagic  foci  are  white  areas  of  fat-necrosis.  Round  cells  and  red 
blood  corpuscles  are  found  in  the  ducts  and  acini,  and  bacteria  are 
present  in  large  numbers.  The  extravasation  of  blood  may  be  ex- 
tensive, involving  the  adjacent  tissue  and  the  various  peritoneal  folds. 


CHRONIC   PANCREATITIS  303 

The  gangrenous  form  is  a  later  stage  of  the  preceding.  The  tip,  or 
even  the  entire  organ,  is  converted  into  an  offensive,  soft,  slate- 
colored  mass.  Partial  or  complete  sequestration  of  the  gland,  in  the 
small  omental  cavity,  may  result,  often  its  only  attachment  being  a 
few  threads.  Peritonitis  accompanies  it,  and  fat-necrosis  may  be 
present.     Thrombosis  of  the  splenic  and  portal  veins  may  occur. 

The  suppurative  form  is  also  a  terminal  affection.  The  pancreas  is 
enlarged  and  the  seat  of  numerous  small  abscesses  and  intervening 
hyperemic  areas.  Diffuse  suppuration  may  occur,  or  in  chronic 
cases  a  solitary  abscess  may  be  formed.  Localized  peritonitis  is 
present  in  many  cases.  Thrombosis  of  splenic  and  portal  veins  may 
also  occur. 

Symptoms. — The  onset  is  sudden  with  intense  abdominal  pain  and 
tenderness  in  the  epigastrium,  and  vomiting.  The  upper  left  quad- 
rant of  the  abdomen  becomes  distended  and  tympanitic,  and  the  tem- 
perature is  slightly  above  or  below  normal.  The  symptoms  of  col- 
lapse soon  present  themselves  and  the  patient  succumbs,  as  arule,  within 
three  days.  The  occurrence  of  chills,  fever,  marked  abdominal  dis- 
tention, tenderness,  and  tympany,  and  jaundice,  in  addition  indicates 
a  termination  by  gangrene.  Suppuration  is  attended  by  irregular 
fever,  jaundice,  constipation,  and  prolongation  of  life  for  three  or 
four  weeks. 

Diagnosis. — This  must  be  made  from  the  symptoms  and  their 
suddenness,  especially  the  circumscribed  tympany.  Intestinal 
obstruction,  perforation  of  the  stomach,  acute  toxic  gastritis,  and 
biliary  colic  resemble  this  affection  in  many  of  its  symptoms,  and  the 
clinical  history  must  be  relied  upon  to  a  great  extent  in  distinguishing 
them. 

Prognosis. — The  disease  is  almost  always  fatal. 

Treatment. — Surgical  intervention  offers  the  only  hope,  as  medic- 
inal measures  are  useless. 

CHRONIC  PANCREATITIS 

Definition. — A  condition  in  which  there  is  interstitial  overgrowth 
of  the  pancreas,  increasing  the  density  and  size  of  that  organ  and 
compressing  the  secreting  structure.  Pigmentary  deposits  may  be 
present,  and  calculi  may  be  lodged  in  the  ducts. 

Causes. — In  rare  instances  it  follows  the  acute  form,  but  more 
frequently  it  is  due  to  arterial  sclerosis,  alcoholism,  syphilis,  obstruc- 


304  CANCER  OF  THE  PANCREAS 

tion  of  the  pancreatic  duct,  extension  from  gastrointestinal  inflamma- 
tion, or  diabetes. 

Sjmiptoms. — There  are  no  characteristic  symptoms.  Paroxysmal 
pain,  abdominal  distention,  indigestion,  diarrhea,  fatty  stools, 
jaundice,  albuminuria,  and  glycosuria  may  be  present  in  varying 
combinations. 

Treatment. — There  is  no  special  treatment  unless  impacted  gall- 
stones are  detected  as  a  cause,  when  surgical  procedures  will  be  found 
very  valuable.  The  elimination  of  fats  and  starches  from  the  diet 
is  advised.  The  treatment  suggested  for  diabetes  mellitus  is  appli- 
cable to  this  condition.  The  course  is  very  slow,  and  with  the  appear- 
ance of  glycosuria,  the  outlook  becomes  proportionately  grave. 

CANCER  OF  THE  PANCREAS 

Pancreatic  cancer  is  a  rare  condition.  The  growth,  as  a  rule,  is 
primary,  and  of  the  scirrhous  variety,  affecting  first  the  head  of  the 
organ.     It  is  most  common  in  males  past  forty  years  of  age. 

Symptoms. — The  most  important  symptoms  are  the  tumor  in  the 
region  of  the  pancreas,  jaundice,  and  fatty  or  greasy  stools.  Associ- 
ated with  these  are  usually  dull  epigastric  pain,  indigestion,  weakness, 
emaciation,  anemia,  and  cachexia.  As  the  tumor  enlarges  and  emacia- 
tion progresses,  the  aortic  pulsation  may  be  transmitted  to  it. 
Ascites  may  result  from  pressure  on  the  portal  vein.  Diabetes 
mellitus  may  also  occur. 

Diagnosis. — The  location  of  the  tumor,  jaundice,  and  fatty  stools 
will  aid  greatly  in  distinguishing  this  affection  from  pyloric  cancer, 
with  which  it  may  sometimes  be  confused. 

Treatment. — The  treatment  is  symptomatic  and  very  unsatisfac- 
tory, as  all  cases  terminate  fatally. 

CYSTS  OF  THE  PANCREAS 

Cystic  tumors  of  the  pancreas  are,  as  a  rule,  retention  cysts  due  to 
the  closure  of  the  duct  of  Wirsung,  by  concretions,  tumors,  or  cica- 
trices, but  they  may  result  from  encapsulation  of  extravasated  blood, 
echinococcus  disease,  or  malignant  tumors.  Congenital  cysts  are 
sometimes  encountered. 

Symptoms. — Fatty  stools  are  exceptional;  but  they  may  be  clay- 
colored  and  putrescent.     An  enlargement  may  be  usually  made  out 


PERITONITIS  305 

in  the  left  portion  of  the  epigastrium,  between  the  costal  cartilages 
and  the  median  line,  which  will  be  globular,  resisting,  and  inelastic. 
Aspiration  of  the  tumor  will  yield  a  fluid  of  brown  or  chocolate 
color,  which  is  capable  of  emulsifying  fats  and  converting  starch  into 
sugar.  Abdominal  pain,  digestive  disturbances,  and  emaciation  ac- 
company it. 

Treatment. — The  treatment  is  surgical  after  withdrawal  of  the 
characteristic  fluid.     The  outlook  is  guardedly  favorable. 

PANCREATIC  CALCULI 

Calculi  in  the  pancreas  may  be  regarded  as  inspissated  particles 
of  altered  pancreatic  secretion,  around  which  concretions  of  car- 
bonate and  phosphate  of  lime  occur.  They  are  multiple  and  about 
the  size  of  a  pea,  being  found  in  the  pancreatic  duct  and  its  branches. 

S3niiptoms. — They  may  be  unattended  by  symptoms  or  there 
may  be  pancreatic  colic,  glycosuria,  fatty  stools,  and  the  passage  of 
calculi  by  the  bowel. 

Treatment. — Morphine  and  atropine  are  required  to  relieve  the 
pain.  Pilocarpine  has  been  advised  for  its  stimulant  effect  on  pan- 
creatic secretion. 

DISEASES  OF  THE  PERITONEUM 

PERITONITIS 

Synonym. — Inflammation  of  the  peritoneum. 

Definition. — A  fibrinous  inflammation  of  the  peritoneum,  either 
acute  or  chronic,  characterized  by  fever,  intense  pain,  tenderness, 
tympanites,  vomiting,  and  prostration.  It  may  be  limited  to  a  part, 
local,  or  it  may  involve  the  entire  membrane,  general,  peritonitis. 

Causes. — The  acute  variety  arises  from  bacterial  infection  and 
may  follow  exposure  to  intense  cold,  protracted  irritation  of  the 
abdomen  by  blisters,  traumatism,  penetrating  wounds  of  the  abdomen, 
inflammation  or  perforation  of  the  stomach,  intestines,  gall-bladder, 
urinary  bladder,  vermiform  appendix,  or  the  surrounding  parts, 
inflammation  of  the  pelvic  viscera,  pyemia,  septicemia,  erysipelas, 
hernia,  pleurisy,  articular  rheumatism,  and  nephritis. 

The  organisms  found  are  the  Staphylococcus  pyogenes  aureus  or 
alhus.  Streptococcus  pyogenes,  Bacillus  coli  communis,  and   Tubercle 
bacillus. 
20 


3o6  PERITONITIS 

• 

The  chronic  variety  may  succeed  an  acute  attack  but  is  more  com- 
monly due  to  tuberculosis,  cancer,  nephritis,  or  syphilis. 

Pathological  Anatomy. — In  the  acute  form,  the  membrane  is  hyper- 
emic,  and  there  may  be  scattered  extravasations  of  blood  from  rup- 
ture of  the  distended  capillaries.  The  secretion  is  arrested  and  the 
peritoneum  becomes  dry,  lusterless,  and  opaque.  The  inflammatory 
exudate  may  be  serofibrinous,  fibrinous,  or  purulent.  The  serous 
or  serofibrinous  exudation  is  productive  of  more  or  less  ascites. 
As  the  fluid  is  absorbed  the  fibrinous  portions  remain  behind  and 
become  organized,  giving  rise  to  adhesions  between  opposing  surfaces. 
If  the  inflammation  subsides  in  the  early  stage,  or  if  the  fibrin  is  in 
excess  from  the  beginning,  adhesions  form  about  ascites.  These 
adhesions  may  serve  to  wall  off  any  localized  purulent  exudation, 
thereby  converting  it  into  an  abscess.  The  inflammatory  process  may 
be  diffused  or  circumscribed. 

In  the  chronic  form,  the  peritoneum  is  thickened  and  studded  with 
tuberculous  or  cancerous  nodules,  as  the  case  may  be.  Adhesions 
are  present  and  serve  to  mat  the  intestines  together,  and  to  disturb 
the  relations  of  the  abdominal  viscera.  There  is  a  varying  quantity 
of  fluid  in  the  cavity,  which  is  albuminous,  but  may,  at  times,  be 
bloody.     The  omentum  is  greatly  thickened  and  shrunken. 

Symptoms. — Acute  peritonitis  is  manifested  by  a  sudden  onset  with 
a  chill,  fever  ioi°  to  i03°F.,  and  a  tense  and  wiry  pulse,  loo  to  140. 
There  is  present  also  intense  abdominal  pain  and  tenderness. 
The  patient  lies  motionless  on  the  back,  with  the  legs  and  thighs 
flexed.  The  expression  is  anxious,  and  the  excruciating  cutting  or 
boring  pain  causes  the  features  to  appear  pinched.  The  abdomen  is 
distended  and  rigid  from  constipation,  effusion,  and  meteorism. 
The  breathing  is  shallow  and  thoracic,  and  the  diaphragm  is  more  or 
less  fixed,  and  in  severe  cases  is  pushed  up  as  far  as  the  third  or  fourth 
rib,  causing  compression  of  the  lungs  and  displacement  of  the  heart, 
liver,  and  spleen.  Impairment  of  appetite,  intense  thirst,  nausea, 
vomiting,  and  hiccough  are  present.  In  the  early  stage,  when  the 
abdomen  is  distended  with  gas,  percussion  will  yield  a  tympanitic  note, 
but  later,  as  the  exudate  is  poured  out,  dullness  will  be  obtained,  cor- 
responding to  the  situation  of  the  exudate ;  small  and  fixed  if  circum- 
scribed, but  if  the  exudate  is  large  and  diffuse,  the  dullness  will  be 
movable.  The  course  of  the  disease  is  rapid,  especially  in  severe 
cases,  collapse  supervening,  being  indicated  by  sudden  normal 
temperature  or  a  rapid  decline  in  the  existing  fever,  cold  clammy  skin. 


PERITONITIS  307 

rapid,  feeble  pulse,  weakness,  and  the  Hippocratic  expression  (sunken 
eyes,  collapsed  cheeks  and  temples,  pinched  nose,  and  drawn  upper 
lip).  The  urine  is  scanty  and  contains  indican.  When  the  condition 
is  produced  by  extension,  it  begins  with  local  and  gradually  increasing 
pain,  tenderness,  and  rigidity,  rising  temperature,  tense  pulse,  and 
vomiting.  When  it  follows  perforation  it  is  ushered  in  with  severe 
pain  and  all  the  symptoms  of  shock.  In  purulent  peritonitis,  hectic 
phenomena  are  present.  In  ordinary  cases,  peritonitis  runs  its  course 
in  from  six  to  eight  days,  terminating  in  collapse  or  a  protracted 
convalescence. 

Chronic  peritonitis  is  usually  of  tuberculous  origin,  and  is  attended 
by  irregular  chills,  fever,  and  sweats,  distended  abdomen,  constipa- 
tion, alternating  with  diarrhea,  diffused  tenderness  with  points  of 
intensity  and  hardness,  colicky  pains  during  digestion,  rapid  emacia- 
tion, anemia,  and  loss  of  strength.  Usually  the  lower  portions  of 
the  abdomen  yield  a  dull  note  on  percussion  from  the  presence  of 
fluid,  or  scattered  by  fixed  points  of  dullness  showing  the  presence  of 
encysted  fluid.  Palpation  may  detect  a  friction  fremitus,  and 
sometimes  the  nodules  may  be  felt.  When  the  fluid  exudate  is  of 
considerable  quantity  fluctuation  may  be  elicited. 

Diagnosis. — The  characteristics  of  acute  peritonitis  are  the 
sudden  onset,  intense  abdominal  pain,  tenderness,  rigidity,  and  dis- 
tention, the  decubitus,  the  quick  wiry  pulse,  the  fever,  the  constipa- 
tion, the  short  course,  and  the  Hippocratic  expression.  These  are 
present  to  a  less  degree  in  chronic  peritonitis,  which  is  most  readily 
distinguished  by  the  history  and  the  results  of  physical  examination. 

A  cute  gastritis  differs  from  peritonitis  in  having  a  history  of  corrosive 
poisoning  or  dietetic  indiscretion,  early  and  severe  vomiting,  severe 
pain  limited  to  the  stomach,  diarrhea,  at  times,  and  no  marked  ab- 
dominal distention,  tenderness,  or  rigidity. 

Acute  enteritis  has  localized  pain  and  tenderness,  and  diarrhea 
is  almost  invariably  present. 

Rheumatism  of  the  abdominal  muscles  is  subacute;  rigidity,  pain, 
and  tenderness  are  present,  but  abdominal  distention,  constipation, 
and  marked  constitutional  symptoms  are  absent. 

Biliary  colic  is  attended  by  pain,  localized  in  most  cases  to  the 
hepatic  area;  rigidity  is  present  to  some  extent;  and  jaundice  is 
common.  The  pain,  tenderness,  rigidity,  and  distention,  as  seen  in 
peritonitis,  are  absent. 

Renal   colic   is   characterized  by   paroxysmal  pain,    which  begins 


3o8  ■         PERITONITIS 

posteriorly  and  follows  the  course  of  the  ureters,  and  is  attended 
by  altered  urinary  secretion  and  retraction  of  the  testicle. 

Typhoid  fever  when  attended  by  marked  distention  and  tenderness 
may  resemble  peritonitis,  but  the  history,  temperature  record,  Widal 
test,  rose-colored  eruption,  and  diarrhea  in  the  former  affection  will 
distinguish  them.  The  occurrence  of  peritonitis,  secondary  to  per- 
foration, in  the  course  of  typhoid  fever,  is  usually  announced  by  a 
fall  of  temperature,  marked  tympanites,  sudden  locaHzed  pain,  quick 
wiry  pulse,  and  collapse. 

Intestinal  obstruction  is  marked  by  absolute  constipation  and 
stercoraceous  vomiting  and  less  abdominal  pain  and  tenderness. 
Rupture  of  an  obstructed  bowel  is  succeeded  by  peritonitis. 

Hysterical  abdomen  may  be  confused  with  peritonitis,  but  its 
occurrence  in  neurotic  women,  its  tendency  to  recur,  and  the  absence 
of  fever  and  the  characteristic  pulse  will  aid  materially  in  making 
the  proper  diagnosis. 

Circumscribed  peritonitis  is  difficult  to  detect  and  requires  for  its 
recognition  a  careful  history  and  physical  examination,  and  often 
the  use  of  the  exploring  needle. 

Prognosis. — In  acute  peritonitis  of  septic  origin  the  termination  is 
fatal  usually  within  a  week.  In  perforative  cases  following  typhoid 
fever.  Keen  has  shown  that  from  15  to  30  per  cent,  recover  with  sur- 
gical treatment  within  twenty-four  hours.  Localized  peritonitis 
is  more  favorable;  an  abscess  may  be  formed  which  may  rupture 
spontaneously  or  be  evacuated  at  a  later  period  by  a  surgeon. 

In  chronic  peritonitis  the  prognosis  is  unfavorable,  but  the  duration 
is  considerably  longer  than  the  acute  form.  Tuberculous  peritoni- 
tis, when  properly  treated,  may  end  in  recovery  or  at  least  suspension 
of  the  disease-process  for  a  considerable  period. 

Treatment. — The  surgeon  should  be  consulted  very  early  in  the 
acute  variety,  as  operation  offers  the  only  hope  in  many  cases,  espe- 
cially those  due  to  perforation.  Counterirritation  may  be  employed, 
but  is  often  useless.  Morphine  and  atropine  hypodermically  will 
relieve  pain,  control  vomiting,  and  lessen  peristalsis.  If  the  stomach 
is  retentive,  ice,  milk  and  lime-water,  champagne,  and  brandy  may 
be  given.  Turpentine  stupes  and  turpentine  enemas  are  frequently 
beneficial.  Belladonna  and  mercury  ointment  applied  locally  is  of 
value  at  times.  Strychnine,  quinine,  and  other  stimulants  may  be 
necessary.  In  non-perforative  cases,  saline  purgatives  may  be 
employed  in  concentrated  solutions,  administering  i  or  2  drams  of 


ASCITES  309 

Rochelle  or  Epsom  salt  every  two  hours  until  there  is  free  bowel 
movement.  In  circumscribed  forms,  leeches,  blisters,  and  hot 
applications  may  produce  considerable  relief.  During  convalescence, 
rest  in  bed,  nutritious  diet,  moderate  stimulation,  and  the  following 
are  indicated: 

I^.     Potassii  iodidi gr.  v  to  x  o . 3  to  o. 6  gm. 

Ferri  pyrophosphat gr.  ij  0. 13  gm. 

Elix.  simpl 5ss  2.0  c.c. 

Aquae  destillatas. .,  .q.  s.  ad   5ij     ad  8.0  c.c. 

M.  S. — To  be  given  every  six  hours. 

Chronic   peritonitis   will   require   the   application   of   tincture   of 
iodine  to  the  abdomen,  rest  in  bed,  and  the  administration  of  opium, 
,  potassium  iodide,  cod-liver  oil,  and  stimulants.     Surgical  treatment 
is  necessary  in  many  cases. 

ASCITES 

Synonyms. — Hydroperitoneum;  abdominal  dropsy. 

Definition. — A  collection  of  serous  fluid  in  the  abdomen,  or  more 
correctly  in  the  peritoneal  cavity;  characterized  by  a  distended 
abdomen,  fluctuation,  dullness  on  percussion,  displacement  of  viscera, 
embarrassed  respiration,  plus  the  symptoms  of  its  cause.  The  quan- 
tity of  fluid  in  the  peritoneal  sac  varies  from  a  few  ounces  to  many 
gallons.  It  is  generally  of  a  straw  color,  or  at  times  greenish,  and  is 
transparent,  and  has  an  alkaline  reaction.  The  specific  gravity  is 
from  loio  to  1020.  When  blood  is  present  in  any  great  quantity 
it  points  to  cancer  as  a  cause.  The  peritoneum  becomes  cloudy, 
sodden,  and  thickened,  from  long  contact  with  the  fluid. 

Causes. — It  may  be  a  part  of  a  general  dropsy  such  as  follows 
chronic  heart,  lung,  or  kidney  disease,  or  it  may  be  due  to  chronic 
peritonitis  or  mechanical  obstruction  of  the  portal  circulation  from 
hepatic  cirrhosis,  portal  thrombosis,  or  abdominal  tumors.  It  may 
accompany  intense  anemia. 

Symptoms.— The  onset  is  gradual  and  considerable  swelHng  of 
the  abdomen  may  occur  before  the  disease  attracts  attention.  The 
umbilicus  is  forced  outward  and  constipation,  scanty  urination,  and 
embarrassed  respiration  and  cardiac  action  result  from  the  pressure 
of  the  accumulated  fluid. 

Physical  examination  reveals  on  inspection,  distention  of  the 
abdomen^  the  surface  of  which  is  smooth  and  shining ;  if  the  distention 


3IO 


ASCITES 


is  excessive,  ''silver  lines"  like  those  observed  in  pregnancy  will  be 
seen;  broadening  of  the  base  of  the  thorax;  bulging  of  the  flanks  when 
the  dorsal  position  is  assumed;  and  enlargement  of  the  superficial 
veins.  On  palpation  a  peculiar  wave-Hke  impulse  is  imparted  to 
the  hand  lying  on  the  side  of  the  abdomen,  while  gently  tapping  the 
opposite  side.  On  percussion  dullness  will  be  obtained  over  the  fluid, 
which  always  seeks  dependent  parts,  above  which  a  tympanitic 
note  will  be  heard.  The  dullness  is  movable,  changing  its  position 
with  the  changes  in  the  patient's  posture. 

Diagnosis. — Ascites  is  to  be  differentiated  chiefly  from  ovarian 
tumor  (or  cyst),  pregnancy,  and  distended  bladder.  The  following 
table  (based  on  one  in  Gould  and  Pyle's  Cyclopedia)  will  aid  in  the 
diagnosis : 


Ascites 


Ovarian    tumors 


Pregnancy 


Distended  bladder 


Frequently  asso- 

ciated with  heart  or 
kidney  disease. 
Navel      often      pro- 
trudes;    caput     me- 
dusae present. 
Percussion-  note 
gives  dullness,   more 
perceptible  in  flanks 
or   lower    abdominal 
region,      where      the 
fluid  gravitates  ; 
movable  dullness. 
Tumor    develops 
from  below  and  ex- 
tends upward. 
No    signs    of    preg- 
nancy; and  health  is 
much  impaired. 
Growth   may  be 
rapid  or  not. 


Heart    and    kid- 
neys normal. 


I.  Same  as  ovarian 
tumor. 


I.  Heart   normal; 
urine  suppressed. 


2.  Same  as  ascites.'  2. 


Percussion  -  note;  3. 
gives     dullness 
rather    high    up ; 
dullness     not 
movable. 


4.  Tumor  develops 
to  right  or  left  of 
median  line.  I 

5.  Same  as  ascites.; 


6.  Slow  growth. 


Abdominal  veins j  2. 
enlarged.  ! 


Abdominal  veins 
normal. 


Same  as  ovarian 
tumors;  suppres- 
sion of  menses. 


Enlargement  de- 
velops in  area  of 
uterus. 

Signs  of  preg- 
nancy; health 
normal. 

Grows  at  a  uni- 
form and  definite 
rate. 


3.  Dullness  immov- 
able; catheter 
confirms  d  i  a  g  - 
nosis. 


4.  Enlargement  de- 
velops in  region 
of  bladder. 

5.  Same  as  ascites. 


Tympanites  is  characterized  by  enormous  distention  of  the  abdo- 
men, but  percussion  yields  universal  tympany. 

Chronic  peritonitis  may  be  differentiated  by  its  history,  pain,  ten- 
derness, more  or  less  vomiting,  thickened  abdominal  walls,  smaller 
effusion  with  less  range  of  motion  due  to  adhesions,  smaller  area  of 
dullness,  and  its  common  association  with  tuberculosis  or  cancer. 

Prognosis.— In  the  common  form  due  to  organic  disease,  the 
prognosis  is  unfavorable,  for  while  the  dropsy  may  be  removed  it 
rapidly  returns.  In  peritoneal  cases  it  is  more  favorable,  and  in 
idiopathic  cases,  which  are  rare,  it  terminates  in  health  within  a  few 
weeks. 


THE    URINE  311 

Treatment. — The  first  indication  is  to  treat  the  cause  of  the  ascites 
and  the  second  to  remove  the  fluid. 

Three  modes  of  removing  the  fluid  present  themselves:  first,  by 
hydragogue  cathartics;  second,  diuretics  and  diaphoretics,  and  third, 
tapping.     The  first  and  second  modes  may  be  combined  as  follows: 

I^.     Pulv.  jalapas  comp 5j  to  ij  4  to  8  gm. 

S. — In  water,  an  hour  before  breakfast. 
And 

I^.     Potassii  acetat gr.  xxx  2 .  gm. 

Spt.  cetheris  nitrosi lUxv  I.  c.c. 

Infus.  digitalis q.  s.  ad  f  5ij  ad  8.  c.c. 

M.  S. — Every  six  hours. 

Or,  instead  use  the  following: 

I^.     Hydrargyri  chlor.  mitis . . . .   gr.  iij  0.2      gm. 

Ext.  opii .   gr.  3^2  0.005  g^n* 

M.  S. — One  every  three  or  four  hours. 

If  these  fail,  as  they  certainly  will  after  a  time,  the  embarrassed 
respiration  and  cardiac  action  will  call  for  tapping,  which  may  be 
performed  with  the  trocar  or  the  aspirator.  The  tapping  does  not 
remove  the  cause,  and  the  fluid  often  rapidly  accumulates  again. 
In  performing  this  operation  the  patient  should  be  placed  in  a  semi- 
recumbent  posture,  and  the  area  selected  (usually  in  the  median  line 
between  the  umbiHcus  and  the  symphysis)  should  be  anesthetized 
by  ethyl  chloride  or  a  mixture  of  ice  and  salt.  After  the  aspirator  has 
been  thrust  into  the  abdomen,  the  trocar  portion  is  withdrawn  and  the 
liquid  flows  through  the  cannula.  Pressure  should  be  made  by 
means  of  a  four-tailed  bandage  to  prevent  collapse.  When  the 
liquid  has  been  entirely  removed  the  instrument  is  withdrawn,  the 
opening  sealed,  and  a  rather  tight  abdominal  binder,  with  a  pad  of 
cotton  or  gauze  applied.  Collapse  should  be  watched  for  and  care- 
fully guarded  against  during  this  procedure.  Before  tapping  always 
examine  the  bladder,  using  the  catheter  if  necessary  or  if  there  is  any 
doubt. 

DISEASES  OF  THE  URINARY  ORGANS 

THE  URINE 

The  normal  quantity  of  urine  voided  varies  from  40  to  50  ounces 
(1200  to  1500  c.c.)  in  the  twenty-four  hours;  the  quantity  depends 


312  THE   URINE 

Upon  the  amount  of  liquids  ingested,  the  amount  of  perspiration 
secreted,  the  temperature  and  moisture  of  the  surrounding  atmos- 
phere, increase  or  decrease  of  blood  pressure,  and  the  presence  or 
absence  of  certain  diseases,  such  as  diabetes,  nephritis,  etc. 

Within  the  twenty-four  hours,  the  least  urine  is  passed  during  the 
night  or  in  the  early  morning,  the  greater  portion  being  passed  during 
the  course  of  the  day. 

An  increase  in  the  quantity  of  urine  excreted  is  termed  polyuria; 
it  may  be  transient  or  permanent.  Transient  polyuria  follows  the 
crisis  of  febrile  affections,  chilling  of  the  skin,  the  administration  of 
diuretics,  the  ingestion  of  large  quantities  of  fluids,  and  similar  condi- 
tions; while  permanent  polyuria  results  from  diabetes  mellitus, 
diabetes  insipidus,  chronic  interstitial  nephritis,  and  amyloid  disease. 

A  diminution  in  the  urinary  secretion  is  termed  oliguria,  and  may 
be  due  to  draining  of  the  fluids  of  the  body  through  other  channels,  as 
in  perspiration  and  diarrhea,  congestion,  and  inflammation  of  the 
kidneys,  fever,  collapse,  hysteria,  or  mechanical  obstruction  some- 
where in  the  genitourinary  tract.  When  complete  it  is  termed  sup- 
pression of  the  urine  or  anuria. 

The  normal  color  is  light  amber,  due  to  pigments,  chiefly  urobilin 
and  uroxanthin;  the  color  deepens  if  the  quantity  voided  be  decreased, 
and  vice  versa.  In  nearly  all  normal  urine  a  cloud  of  mucus  forms 
after  standing  a  short  time. 

The  normal  reaction  is  slightly  acid,  due  almost  entirely  to  acid 
sodium  phosphate  (NaH2P04) ;  the  acidity  is  not  due  to  uric  or  hip-, 
puric  acids.     After  meals,  it  may  be  neutral  or  even  alkaline. 

The  normal  specific '  gravity  varies  from  1.015  to  1.025;  it  is  low 
when  an  increased  quantity  is  passed,  and  high  when  the  quantity 
is  diminished.  Urine  of  a  high  specific  gravity  is  found  in  diabetes 
mellitus,  fevers,  diarrhea,  and  after  large  hemorrhages  and  profuse 
perspiration.  Urine  of  a  low  specific  gravity  is  found  in  diabetes 
insipidus,  chronic  interstitial  nephritis,  amyloid  disease,  nervous  ex- 
citement, hysteria,  and  after  the  ingestion  of  alcohol. 

The  total  solids  in  urine  may  be  approximately  obtained  by 
multiplying  the  last  two  figures  of  the  specific  gravity  by  2  (Trapp's 
coefficient);  this  gives  the  number  of  grams  per  liter.  Thus,  if  a 
given  sample  of  urine  has  a  specific  gravity  of  1.015,  it  will  contain, 
approximately,  15x2  =  30  grams  per  liter;  if  1500  c.c.  be  passed  in 
twenty-four  hours,  the  solids  will  total  30x1.5  =  45  grams. 

The  normal  odor  of  urine  is  a  peculiar,  well-known,  aromatic  one ; 


THE   URINE 


313 


it  is  altered  by  certain  foods,  for  instance,  the  violet  stench  after 
eating  asparagus,  and  the  garlicky  odor  after  using  garlic. 

The  average  composition  of  normal  urine  is  given  as  follows: 


(Parts  in 
1000) 

Water 950 .  00 

Urea 28  .  00 ' 

Uric  acid. 0.60 

Hippuric  acid 0  .35 

Creatinin o  .  65 

Extractives 8 .  00 


Sodium  chloride 

Phosphoric  acid 

Sulphuric  acid 

Lime  (CaO) 

Magnesia  (MgO) 

Potash  (K2O)  and  soda  (Na20) . 


8.00 
2  .00 

I. 25 
0.25 

0.30 
0.60 


Voided 

per  day 

Grains 

Grams 

520.80 

35.00 

Organic 

II. 16 

0.75 

matter. 

6.51 

0.44 

37-60. 

12.09 

0.81 

148.80 

10.00 

148.80 

10.00 

37.20 

2.50 

Inorganic 

34-45 

1.56 

matter. 

4-65 

0.31 

12  .40 

5. 58 

0.37 

II. 16 

0.75 

Total 1000 .  00 


930.20       62.49 


Urea  may  be  increased  in  febrile  affections,  diabetes,  in  chronic 
interstitial  nephritis,  and  acute  inflammatory  conditions,  and  after 
the  ingestion  of  excessive  quantities  of  albuminous  food  and  certain 
drugs. 

A  diminution  in  the  quantity  of  urea  usually  indicates  deficient 
elimination,  and  is  observed  in  nephritis,  especially  in  the  late  stages, 
cachectic  conditions,  acute  yellow  atrophy  of  the  liver,  hepatic  cir- 
rhosis, diarrhea,  acute  gout,  chronic  rheumatism,  leprosy,  pemphigus, 
melancholia,  catalepsy,  hysteria,  and  after  free  perspiration,  fasting, 
and  a  vegetable  or  milk  diet. 

The  presence  of  urea  may  be  determined  qualitatively  by  the 
addition  of  nitric  acid  to  urine  which  has  been  evaporated  to  about 
one-sixth  its  original  volume.  Crystals  of  urea  nitrate  will  then 
be  formed.  For  the  quantitative  determination  of  urea  in  the  urine, 
two  tests  are  employed — Davy's  and  Fowler's  tests. 

Davy's  Hypobromite  of  Sodium  Test. — Fill  a  graduated  glass  tube 
one-third  full  of  mercury,  and  add  }i  dram  of  the  twenty-four 
hours'  urine;  then  fill  the  tube  evenly  full  with  a  saturated  solution 
of  hypobromite  of  sodium,  and  close  it  immediately  with  the  thumb ; 
invert  the  tube  and  place  its  open  end  beneath  a  saturated  solution 
of  chloride  of  sodium ;  the  mercury  flows  out  and  is  replaced  by  the 
solution  of  salt;  nitrogen  gas  is  disengaged  from  the  urea  in  the  upper 
part  of  the  tube.  Each  cubic  inch  of  gas  represents  0.645  gr.  of 
urea  in  the  half-dram,  from  which  the  amount  passed  in  twenty- 
four  hours  may  be  calculated. 

Fowler's  Sodium  Hypochlorite  Test. — This  test  depends  upon  the 


314 


THE   URINE 


reduction  in  density,  caused  by  the  decomposition  of  urea  in  solution 
by  sodium  hypochlorite.  In  a  mixture  of  one  volume  of  urine  and 
seven  volumes  of  sodium  hypochlorite  solution,  a  loss  of  one  degree 
in  specific  gravity  represents  the  decomposition  of  0.77  per  cent,  of 
urea.  The  specific  gravity  of  the  urine  should  always  be  taken  first. 
The  specific  gravity  of  the  mixture  of  the  urine  and  the  hypochlorite 
solution  (Labarraque's  solution)  should  then  be  ascertained  by 
multiplying  that  of  the  pure  sodium  hypochlorite  solution  by  seven, 
adding  to  this  the  specific  gravity  of  the  urine,  and  dividing  by  eight. 
The  mixture  (i  part  urine  and  7  parts  hypochlorite  solution) 
is  set  aside  for  about  two  hours  to  allow  complete  decomposition, 
when  the  specific  gravity  is  again  taken  and  compared  with  that  of 
the  urine. 

Uric  acid  or  urates  in  the  urine  constitute  the  condition  known 
as  lithuria.     When  in  excess  in  the  urine  they  are  precipitated  by 


Fig.  27. — Uric  acid  crystals. 
Medical  Diagnosis.) 


{Greene's 


Fig.  28. — Ammonio-magnesium       (triple) 
phosphate.    {Greene's  Medical  Diagnosis.) 


cold  as  brickdust  deposits.  Their  quantity  is  increased  in  indigestion, 
gout,  fever,  wasting  diseases,  malaria,  scurvy,  diabetes,  rachitis, 
and  after  free  perspiration  and  diarrhea,  and  the  ingestion  of  nitrog- 
enous foods,  colchicum,  salicylic  acid,  and  corrosive  sublimate. 
They  are  diminished  in  amount  in  an  acute  attack  of  gout,  anemia, 
chlorosis,  chronic  nephritis,  and  after  the  use  of  drugs,  such  as  caffeine 
lithia,  potassium  iodide,  etc. 

Tests  for  Uric  Acid  and  Urates. — The  urine  should  be  evaporated 
to  dryness  on  a  water-bath  and  covered  with  strong  nitric  acid, 
after  which  the  mixture  is  again  evaporated.  When  cool  a  drop  or 
two  of  ammonium  hydroxide  is  added  to  the  residue,  whereupon  a 


THE   URINE 


315 


beautiful  red  color  will  be  produced  by  the  formation  of  murexide 
or  ammonium  purpurate. 

The  contact  test  consists  in  pouring  nitric  acid  slowly  down  the 
side  of  a  test-tube  containing  a  small  quantity  of  urine.  At  the 
junction  of  the  two  liquids  a  yellowish-red  zone  will  be  formed  by 
the  uric  acid,  while  above  this  will  be  a  dense  milky  zone  of  acid  urates, 
which  dissolves  on  agitation. 

For  the  quantitative  determination  of  uric  acid,  three  ounces  of  the 
twenty-four  hours'  urine  (after  being  slightly  acidulated,  boiled,  and 
filtered  while  hot)  should  be  mixed  with  one-tenth  as  much  nitric  acid 
and  placed  in  a  cool  place  for  twenty-four  hours.  The  uric  acid 
crystals  are  then  collected  on  a  weighed  filter,  washed,  and  dried  at 
2i2°F.  The  increased  weight  represents  the  quantity  of  uric  acid  in 
3  ounces  of  urine. 


Fig.  29. — Ammonium  urate. 
{Greene's  Medical  Diagnosis.) 


Fig.  30. — Calciumi  oxalate  crystals. 
{Greene's  Medical   Diagnosis.) 


Phosphates  occur  in  the  urine  as  ammonio-magnesium  or  triple 
phosphates,  and  as  crystalline  and  amorphous  phosphate  of  calcium. 
They  are  precipitated  in  alkaline  urine  and  often  produce  a  cloudiness 
when  the  urine  is  heated,  which  disappears  on  the  addition  of  nitric 
or  acetic  acid.  The  addition  of  an  alkali  such  as  ammonium  hydrox- 
ide to  urine  containing  amorphous  phosphates  causes  their  precipita- 
tion. Triple  phosphates  may  be  recognized  under  the  microscope  by 
their  large  rhombic  or  "coffin-lid"  shaped  prisms,  which  are  freely 
soluble  in  acetic  acid.  Crystalline  phosphate  of  calcium  is  a  rare 
form  and  appears  as  rods  or  needles,  sometimes  grouped  together  as 
sheaves  or  stars,  which  are  also  soluble  in  acetic  acid.  An  excess  of 
phosphates  in  the  urine  constitutes  phosphaturia,  and  occurs  in 
rachitis,  osteomalacia,  gout,  nervous  dyspepsia,  and  various  nervous 


3i6 


THE   URINE 


affections.  They  are  apparently  in  excess  in  alkaline  urine.  Triple 
phosphate  in  combination  with  amorphous  phosphates,  bladder 
epithelium,  and  pus  cells  in  freshly  voided  urine  indicates  cystitis. 

The  magnesium  test  for  phosphates  consists  in  the  addition  of  a  mix- 
ture of  I  part  each  of  magnesium  sulphate,  ammonium  chloride,  and 
ammonium  hydroxide  and  8  parts  of  distilled  water  to  three  times  as 
much  urine,  whereupon  a  cloudy,  milky  precipitate  will  be  formed 
which  will  be  creamy  if  the  phosphates  are  in  excess. 

Chlorides  are  increased  in  the  urine  after  exertion  of  any  kind,  in 
acute  Bright's  disease,  diabetes  insipidus,  and  during  absorption  of 


Fig.  31. — A,  crystals  of  cystin. 


B,  crystals  of  oxalate  of  lime. 
B.   (Landois.) 


C,  hour-glass  forms  ot 


exudates;  and  are  diminished  in  pneumonia,  febrile  affections,  and 
chronic  nephritis,  and  wasting  diseases.  To  test  for  their  presence, 
albumin  should  first  be  removed  by  nitric  acid,  or  boiling  and  filtra- 
tion, after  which  i  drop  of  silver  nitrate  solution  (i  part  to  8)  should 
be  added.  The  presence  of  chlorides  will  be  indicated  by  a  white 
precipitate  of  silver  chloride. 

Oxalates  are  recognized  only  by  microscopic  examination,  and 
occur  as  dumb-bell  shaped  crystals  or  octahedral  crystals.  Their 
presence  is  termed  oxaluria,  and  indicates  impeded  metamorphosis. 
It  is  encountered  in  diabetes,  after  the  ingestion  of  pears,  rhubarb, 


THE    URINE 


317 


Spinach,  and  similar  substances,  in  certain  forms  of  indigestion,  in 
gout,  and  in  certain  nervous  affections.  It  is  accompanied  by  pains 
in  the  back  and  loins,  flatulence,  dyspepsia,  hypochondriasis,  and 
melancholia. 

Cystin  is  a  rare  sediment  sometimes  observed  in  the  urine  of  chil- 
dren, and  young  male  adults,  and  in  occasional  instances  it  forms  a 
basis  for  a  calculus.  It  occurs  as  hexagonal  plates  which  may  be 
superimposed  upon  each  other  or  grouped  in  irregular  masses. 

Leucin  appears  in  the  urine  as  highly  refracting  spheres,  which 
have  a  radiating  arrangement  and  are  insoluble  in  ether.  They  are 
usually  combined  with  tyrosin  crystals,  which  are  long  and  needle- 
like, in  acute  yellow  atrophy  of  the  liver,  and  phosphorus  poisoning. 
Tyrosin  may  also  be  found  in  typhoid 
fever. 

Cholesterin  plates  may  be  encountered 
in  the  urine  in  jaundice,  chyluria,  fatty 
degeneration  of  the  kidneys,  and  diabetes 

Mucus  alone  is  not  visible,  but  induces 
cloudiness  from  having  entangled  and 
precipitated  mucus  or  pus  corpuscles, 
epithelium,  and  various  crystals.  To 
detect  its  presence  a  few  drops  of  acetic 
acid  are  added  to  the  urine,  thereby  ren- 
dering visible  threads  and  bands  of 
mucin  which  are  dissolved  on  the  addi- 
tion of  nitric  acid  (and  see  Pus  on  page  321). 

Albiunin  occurs  in  the  urine  usually  in  the  form  of  serum  albumin, 
but  other  proteids  may  also  be  found.  It  is  encountered  in  congestion 
and  inflammation  of  the  kidneys,  anemic  conditions,  pregnancy, 
acute  febrile  diseases,  diarrhea,  cholera,  certain  nervous  diseases  as 
meningitis,  cerebral  hemorrhages,  epilepsy,  etc.,  and  in  healthy  adults 
after  exertion,  exposure,  or  a  rich  diet.  Contamination  of  the  urine 
with  blood  or  pus,  anywhere  along  the  genitourinary  tract  produces 
the  form  known  as  extrarenal  albuminuria. 

Heller's  Test. — A  small  quantity  of  nitric  acid  should  be  placed 
in  the  test-tube  and  an  equal  quantity  of  urine  superimposed  upon 
it  by  means  of  a  pipette.  A  white  zone  at  the  line  of  junction  will 
result  if  albumin  is  present.  A  diffuse  pink  ring,  slightly  above 
the  line  of  contact,  indicates  the  presence  of  uric  acid.  Balsam 
of  copaiba,  oleoresin  of  cubebs,  turpentine,  and  similar  drugs,  when 


Fig.   32. — Tyrosin.       {Greene's 
Medical  Diagnosis.) 


3i8 


THE   UEINE 


ingested,   give  rise  to  the  same  reaction  in  the  urine  as  albumin, 
but  their  rings  are  dissolved  by  the  addition  of  alcohol. 

Heat  and  Nitric  A  cid  Test. — The  urine  is  slightly  acidulated  and 
boiled.  A  white  deposit,  which  is  not  dissolved  by  the  addition  of 
nitric  acid,  drop  by  drop,  is  due  to  coagulated  albumin.  An  excess 
of  the" acid  will  cause  solution  of  the  precipitate. 

Johnson's  Picric  Acid  Test. — Filtered  urine  should  be  placed  in  a 
test-tube  and  a  saturated  solution  of  picric  acid  is  added,  drop  by 
drop;  in  the  presence  of  albumin  an  opaque  white  cloud  will  be 
formed,  which  is  rendered  more  marked  on  the  appHcation  of  heat. 
Quantitative  Test. — For  the  determination  of  the  quantity  of  al- 
bumin Esbach's  albuminometer  is  most  convenient.  The  tube  should 
first  be  filled  up  to  the  mark  "U"  with  urine.  The  reagent,  consist- 
ing of  picric  acid  lo  gm.,  citric  acid  20  gm.,  and  water  i  liter,  should 
be  poured  over  the  urine  until  the  mark  "R"  is  reached.  The  rubber 
stopper  is  then  inserted  and  the  contents  of  the 
tube  thoroughly  admixed  by  gentle  shaking. 
The  tube  is  then  set  aside  for  twenty -four  hours, 
when  a  precipitate  will  have  formed  and  its 
quantity  will  indicate  on  the  graduated  scale  on 
the  tube  the  number  of  grams  of  albumin  to  the 
liter  of  urine. 

Sugar  in  the  urine  or  glycosuria  may  be 
present  normally,  after  the  ingestion  of  large 
quantities  of  saccharine  substances,  but  is 
usually  present  as  an  abnormal  constituent  in 
diabetes  mellitus,  and  diseases  of  the  pancreas. 
It  may  also  occur  in  diseases  or  injuries  of  the  floor  of  the  fourth 
ventricle,  certain  nervous  diseases,  pregnancy,  and  poisoning  by 
drugs,  such  as  chloroform,  nitrites,  etc. 

Moore's  test  for  sugar  consists  in  boiling  the  urine  with  half  its 
volume  of  sodium  or  potassium  hydroxide  solution  (10  per  cent.). 
Should  a  white  flaky  precipitate  of  earthy  phosphates  be  formed, 
it  should  be  removed  by  filtration  and  the  urine  again  boiled.  If 
glucose  is  present,  the  liquid  then  becomes  brown  and  finally  black, 
due  to  the  formation  of  glucic  and  finally  melassic  acid. 

Boettger's  bismuth  test  requires,  first,  the  addition  of  the  urine 
to  half  its  volume  of  sodium  or  potassium  hydroxide  solution,  after 
which  a  small  portion  of  bismuth  subnitrate  is  mixed  with  the 
resultant  liquid    and  the  whole  shaken  together  and  boiled.     The 


Fig.    33. — Cholesterin. 
(JLandois.) 


THE   URINE  319 

presence  of  sugar  reduces  the  salt,  and  black  metallic  bismuth  is 
deposited.  If  there  is  but  little  glucose,  a  gray  precipitate  is  formed. 
If  there  is  any  reason  to  suspect  the  presence  of  albumin,  it  should 
be  removed  before  applying  this  test,  as  it  interferes  by  forming 
bismuth  sulphide,  which  is  also  black. 

Johnson^s  picric  acid  test  is  applied  by  adding  a  few  drops  of  a 
saturated  solution  of  picric  acid  to  urine,  which  has  been  previously 
rendered  alkaline  by  means  of  a  sodium  or  potassium  hydroxide  solu- 
tion and  boiling  the  mixture,  which  then  becomes  claret-red  in 
color  in  the  presence  of  glucose.     Creatinin  gives  a  similar  reaction. 

Trommer's  test  is  performed  by  adding  to  the  urine  a  few  drops  of 
a  solution  of  cupric  sulphate,  and  then  its  own  volume  of  a  potassium 
hydroxide  solution,  after  which  the  entire  mixture  is  boiled.  The 
immediate  formation  of  a  yellowish  precipitate  of  hydrated  cupric 
suboxide  denotes  the  presence  of  sugar. 

The  phenyl-hydrazine  test  requires  for  its  reagent  a  mixture  of  2  gr. 
of  phenyl-hydrazine  hydrochloride  and  3  gr.  of  sodium  acetate  dis- 
solved in  half  a  test-tube  full  of  water,  by  heating.  The  test-tube 
is  then  filled  with  the  suspected  urine  and  placed  in  boiling  water 
for  fifteen  or  twenty  minutes.  It  is  then  placed  in  cold  water. 
If  the  sugar  is  present  in  large  amounts  a  yellow  precipitate  of 
needle-like  crystals  may  be  observed  with  the  unaided  eye,  but 
ordinarily  the  microscope  is  necessary  to  detect  these  crystals  of 
phenyl-glucosazon. 

Quantitative  Tests  for  Glucose. — Fehling's  test  necessitates  fresh 
preparation  of  the  reagent  before  its  application.  Two  solutions  are 
employed:  the  first  consists  of  34.652  gm.  of  pure  cupric  sulphate 
dissolved  in  distilled  water  and  diluted  up  to  500  c.c,  the  second 
consists  of  175  gm.  of  pure  Rochelle  salt  and  60  gm.  of  caustic  soda, 
dissolved  in  400  c.c.  of  distilled  water  and  boiled,  after  which  it  is 
made  up  to  500  c.c.  with  distilled  water.  The  Fehling's  solution 
proper  js  made  by  mixing  equal  quantities  of  the  foregoing  solutions, 
and  its  preparation  is  such  that  i  c.c.  of  it  will  reduce  0.005  g^^-  ^^ 
glucose.  In  applying  this  test,  i  c.c.  of  Fehling's  solution  is  boiled 
with  4  c.c.  of  distilled  water  to  test  it.  If  the  solution  remains  clear 
the  urine  is  added,  drop  by  drop,  by  means  of  a  graduated  pipette, 
from  which  2  drops  equal  >f  0  c.c.  The  number  of  drops  necessary 
to  change  all  of  the  blue  color  of  the  solution  to  yellowish  red,  on 
boiling,  should  be  noted  and  divided  by  two,  thus  giving  the  number 
of  Ko  c-c.  required.      If  i  c.c.  has  been  required  for  this  purpose,  it 


320  THE   URINE 

indicates  the  presence  of  0.5  per  cent,  of  sugar,  and  if  2  c.c.  have  been 
employed  the  percentage  will  be  0.25.  This  result  is  obtained  by 
dividing  the  number  5  by  the  number  of  tenths  of  urine  required  to 
reduce  the  Fehling's  solution. 

Fehling's  test  is  not  advised  for  merely  detecting  the  presence  of 
sugar,  because  uric  acid  is  also  capable  of  reducing  Fehling's  solution. 
French  well  remarks  that  uric  acid  seldom  gives  the  copious  brick- 
red  or  orange-yellow  precipitate  that  is  characteristic  of  abundance 
of  sugar,  but  it  may  give  just  enough  reduction  or  change  of  color 
to  make  it  doubtful  whether  sugar  is  present  or  not.  More  than  a 
few  proposers  for  life  insurance  have  suffered  unfairly  on  this  account, 
no  such  partial  reduction  should  be  regarded  as  due  to  sugar  until 
the  presence  of  glucose  has  been  confirmed  by  other  means,  particu- 
larly the  phenyl -hydrazine  and  the  fermentation  tests. 

Roberfs  differential  density  test  consists  in  taking  two  measured 
specimens  of  the  urine,  to  one  of  which  is  added  a  sm.all  piece  of 
yeast.  Both  are  placed  in  a  chamber  at  a  temperature  from  75°  to 
8o°F.  for  twenty-four  hours,  after  which  the  specific  gravity  of  each 
is  taken.  The  presence  of  sugar  will  cause  a  loss  of  specific  gravity, 
and  the  number  of  degrees  lost  will  correspond  approximately  to  the 
number  of  grains  of  sugar  in  each  ounce  of  urine. 

Blood. — Blood  occurs  in  the  urine  in  two  forms:  (i)  hematuria,  in 
which  hlood  corpuscles  are  in  the  urine;  and  (2)  hemoglobinuria,  in 
which  blood  pigment  is  in  the  urine. 

In  hematuria  a  microscopical  examination  will  show  numerous  red 
blood  corpuscles  in  the  urine;  in  the  other  condition  red  cells  are 
either  absent  or  are  very  scanty. 

The  principal  causes  of  hematuria  are:  (i)  conditions  in  which  the 
blood  is  affected,  as  in  the  infectious  diseases,  in  scurvy,  pernicious 
anemia,  and  purpura;  (2)  traumatism  or  inflammations  in  any  part 
of  the  urinary  tract;  (3)  congestion  of  the  kidneys  secondary  to  dis- 
ease of  the  lungs,  heart,  or  liver. 

The  principal  causes  of  hemoglobinuria  are:  poisons,  such  as  arsenic, 
potassium  chlorate,  carbolic  acid,  carbon  monoxide;  jaundice, 
malaria,  syphiHs,  Raynaud's  disease,  scurvy,  purpura;  condition  of 
hemolysis,  such  as  blackwater  fever. 

Source  of  the  Hemorrhage. — This  can  readily  be  ascertained  as 
follows :  if  the  blood  is  chiefly  in  the  first  urine  passed,  it  comes  from 
the  urethra;  if  in  the  last  only  or  chiefly,  it  is  from  the  bladder;  and  if 
the  blood  and  urine  are  well  mixed  it  is  from  the  kidneys. 


THE    URINE  321 

Tests  Jor  Blood. — Heat  with  nitric  acid  causes  a  deposition  of  the 
albumin  of  the  blood,  with  changing  of  its  coloring  matter  to  a  dirty- 
brown. 

Heller^s  test  consists  in  boiling  the  urine,  then  adding  caustic  soda 
and  continuing  to  boil,  thus  causing  a  precipitation  of  the  phosphates 
and  coloring  matter  of  the  blood,  which  deposit  appears  of  a  brownish- 
red  color  and  the  supernatant  fluid  of  a  bottle-green  color. 

The  microscope  and  spectroscope  should  also  be  employed  as  con- 
firmatory tests. 

Bile. — The  presence  of  biliary  pigments  may  be  crudely  determined 
by  agitating  the  urine,  whereupon  a  yellow  foam  is  produced.  A 
simple  test  is  to  filter  the  urine  through  white  filter  paper ;  then  place 
the  paper  on  a  porcelain  dish  or  plate  and  add  a  drop  of  strong  nitric 
acid.  In  the  presence  of  bile  pigment,  concentric  rings  of  red,  violet, 
blue,  and  green  will  be  formed  at  the  line  of  contact. 

Gmelifi's  test  is  performed  as  follows:  put  3  c.c  of  nitric  acid  in  a 
test-tube,  add  a  small  piece  of  wood  (a  piece  of  a  match  will  do),  and 
heat  until  the  acid  is  yellow;  let  it  cool.  When  cold,  float  on  the 
surface  of  the  acid  some  of  the  urine  to  be  tested.  In  the  presence  of 
bile,  there  will  be  a  green  band  at  the  junction  of  the  two  liquids,  and 
this  will  gradually  rise,  and  be  succeeded  by  blue,  violet,  and  yellow. 

Pettenkofer's  test  consists  first  in  the  addition  of  a  few  grains  of  cane- 
sugar  and  a  drop  or  two  of  sulphuric  acid  to  the  urine,  after  which  the 
entire  mixture  is  boiled.  The  formation,  if  a  violet-red  color,  indi- 
cates the  presence  of  biliary  pigments. 

Pus. — The  presence  of  pus  in  the  urine  is  termed  pyuria  and  usually 
indicates  suppuration  along  the  genitourinary  tract.  Its  source 
may  be  detected  to  a  great  extent  by  the  time  of  its  appearance  in 
flow,  as  with  blood  in  the  urine.  When  present  in  the  early  part  of 
micturition  the  urethra  is  usually  diseased,  if  at  the  end  and  in  alka- 
line urine  the  trouble  is  in  the  bladder,  but  if  it  is  freely  admixed  with 
an  acid  or  neutral  urine,  the  probabilities  are  that  the  kidneys  are  at 
fault.  The  addition  of  an  equal  quantity  of  a  solution  of  potassium 
hydroxide  to  urine  containing  pus  gives  rise  to  the  formation  of  a 
viscid  gelatinous  mass.  (Mucus  treated  similarly  is  dissolved.) 
The  microscope  may  also  be  employed  to  detect  pus. 

Acetone. — Acetone  occurs  in  the  urine  in  the  advanced  stages  of 
diabetes,  in  starvation,  in  cancer,  in  autointoxications,  in  digestive 
disturbances,  in  fevers,  in  certain  psychoses,  and  to  a  very  slight 
extent  in  health. 
21 


322  THE   URINE 

LegaVs  test  for  its  detection  consists  in  the  addition  of  a  few  drops 
of  a  strong  solution  of  sodium  nitroprusside  to  about  4  c.c.  of  urine 
which  has  been  previously  rendered  alkaline  by  potassium  hydroxide 
solution.  In  the  presence  of  acetone  a  red  color  is  produced,  which 
turns  purple  on  the  addition  of  a  few  drops  of  acetic  acid. 

It  may  also  be  detected  by  the  precipitation  of  iodoform,  which 
occurs  when  urine  containing  it  is  mixed  with  a  few  drops  of  iodopo- 
tassium  iodide  solution  and  sodium  hydroxide  solution. 

Diacetic  Acid. — Diacetic  acid  occurs  in  children  in  fevers,  in  dia- 
betes, and  in  autointoxications.  Coma  usually  follows  its  appearance. 
To  detect  its  presence  the  urine  should  be  boiled  with  a  solution  of 
ferric  chloride,  and  if  diacetic  acid  is  present,  a  Burgundy-red  color 
will  be  produced. 

Indican. — The  presence  of  indoxyl-potassium  sulphate  or  indican 
in  the  urine  is  termed  indicanuria.  It  is  a  sign  of  intestinal  putrefac- 
tion and  is  observed  after  the  ingestion  of  an  animal  diet,  in  ileus, 
peritonitis,  diarrhea,  and  intestinal  tuberculosis.  It  also  accom- 
panies decomposition  of  albumin  in  cavities,  and  is  encountered 
in  empyema  and  puerperal  peritonitis.  It  is  not  present  in  simple 
constipation. 

Jaffe's  test  consists  in  mixing  10  c.c.  of  strong  hydrochloric  acid 
with  an  equal  volume  of  urine,  from  which  albumin  has  been  removed, 
and  while  shaking  add,  drop  by  drop,  a  freshly  prepared  saturated 
solution  of  chloride  of  lime.  Chloroform  is  then  added,  which  dis- 
solves out  an  indigo-blue  substance  if  indican  is  present. 

Another  method  sometimes  employed  requires  the  addition  of  20 
drops  of  urine  to  4  c.c.  of  hydrochloric  acid.  If  the  proportion  of 
indigo  be  slightly  above  normal,  the  resultant  color  will  be  rather 
light  yellow;  if  in  excess  the  acid  will  turn  violet  or  blue — the  color 
being  more  intense  the  greater  the  quantity.  If  no  coloration  ap- 
pears within  a  minute  or  two  there  is  no  excess  of  indican. 

Peptone. — Peptone  may  be  encountered  in  the  tirine  in  jaundice, 
hepatic  cancer,  acute  miHary  tuberculosis,  scarlet  fever,  and  typhoid 
fever. 

Ralfe's  test  is  performed  by  adding  4  c.c.  of  Fehling's  solution  to 
a  small  quantity  of  urine  by  means  of  a  pipette.  Peptone  will  be 
indicated  by  a  rose-colored  halo  immediately  above  the  line  of 
contact. 

Ehrlich's  Diazo-reaction. — The  presence  of  aromatic  substances 
in  the  urine,  such  as  occur  in  typhoid  fever,  pneumonia,  measles, 


THE   URINE 


323 


tuberculosis,  diphtheria,  scariet  fever,  and  septic  infection,  may  be 
detected  by  the  following  test: 

I.  Take  2  gm.  (30  gr.)  of  sulphanilic  acid,  50  c.c.  of  hydrochloric 
acid,  and  1000  c.c.  of  distilled  water. 

II.  Take  solution  sodium  nitrite  in  water  of  the  strength  of  0.5 


Fig.  34. — Illustrating  the  Forma- 
tion OF  Casts.  (Rindfleisch.) 
a.  Hyaline  casts  in  place.  If  it 
comes  away  bringing  nothing  with  it, 
it  will  remain  a  hyaline  cast.  If  it 
brings  epithelium,  it  will  be  an 
epithelial  cast;  if  the  epithelium  is 
granular,  it  will  be  a  granular  cast;  if 

^  fatty,  a  fatty  cast.     c.  Granular  cast. 

i  The  two  casts  in  the  lower  corner  and 
to  the  left  are  hyaline;  the  remaining 
casts  are  largely  hyaline,  but  bear  a 
few  epithelial  cells. 


Fig. 
cells 
cast. 


35. — Blood 
and  blood- 
(Landois.) 


per  cent.  Place  50  parts  of 
No.  I  and  i  part  of  No.  II  in 
a  test-tube  and  add  equal 
amount  of  urine.  The  entire 
is  rendered  strongly 
by     strong     ammonia 


mixture 
alkaline 
water. 

If    the    diazo-reaction    occurs 
the    mixture    becomes    carmine 
red;  now  shake  the  tube,   and 
if  the  red  color  is  seen  in  the 
Allow  the  tube  to  stand  a  day,  and 


foam  the  test  is  complete, 
a  green  precipitate  forms. 

Russo's  Test. — This  is  also  used  as  an  aid  in  the  diagnosis  of 
typhoid  fever,  and  it  is  said  to  be  of  more  value  than  EhrHch's  diazo- 
reaction.  A  few  drops  of  methylene  blue  (i  :  1000)  are  added  to  the 
urine  on  the  second  day  of  the  fever,  an  emerald-green  tint  results 
in  the  presence  of  typhoid;  normal  urine  gives  a  Hght  green  or  bluish- 
green  color.  The  same  reaction  occurs  in  smallpox  and  measles, 
but  it  is  absent  in  miliary  tuberculosis. 

Microscopical  Examination. — For  the  determination  of  substances 
by  the  microscope,  other  than  the  crystals  already  mentioned,  it  is 


324 


THE   URINE 


necessary  to  produce  first,  a  sediment  by  means  of  the  centrifuge, 
or  in  its  absence,  by  allowing  the  urine  to  stand  for  twelve  or  twenty- 
four  hours  after  having  added  lo  drops  of  chloroform,  5  gr.  of  chloral, 
formalin,  or  a  few  drops  of  carbolic  acid  to  prevent  decomposition. 

In  all  microscopical  examinations  of  urinary  sediment,  do  not 
allow  more  light  on  the  stage  than  is  absolutely  necessary,  the  dimmer 
the  better;  and  focus  carefully. 

Tuhe-casts  should  always  be  carefully  sought  for  in  the  sediment. 
They  are  molds  of  the  uriniferous  tubules  and  vary  in  character 


Fig.  36. — Epithelial  Casts.  (Landois.) 
A,  Epithelial  cast,  the  lower  end  of  which 
is  coarsely  granular;  B,  epithelial  cast  in 
which  the  epithelial  cells,  thoiigh  themselves 
granular,  have  not  broken  up. 


Fig.  37. — Granular  Casts.  (Landois.) 
A,  Granular  casts  in  which  the  gran- 
ules are  fine  and  the  dissolution  of  the 
epithelial  cells  is  complete;  B,  granular 
casts  in  which  the  granules  are  coarse 
and  the  outlines  of  the  epithelial  cells 
at  points  faintly  distinguishable. 


according  to  the  existing  abnormal  condition  of  the  kidneys.  Usually 
they  are  composed  of  albuminoid  substances,  but  there  may  be  in 
addition  epithelium,  degenerated  cells,  blood  corpuscles,  or  fat  glob- 
ules. Their  length  is  about  200  microns  or  more,  and  their  width 
from  4  to  40  microns.  While  usually  straight,  they  may  be  curved 
or  twisted  upon  themselves. 

Blood-casts  are  composed  of  coagulated  blood  and  blood  cells, 
and  point  to  the  presence  of  some  hemorrhagic  condition  of  the 
kidney.  Often  the  cast  is  in  reality  a  hyaline  cast  studded  with 
blood  corpuscles. 

Epithelial  casts  may  also  be  considered  as  hyaline  casts  covered 


THE    URINE 


325 


and  infiltrated  with  epithelial  cells.  They  denote  desquamation, 
and  are  seen  in  the  urine  in  acute  parenchymatous  nephritis. 

Fatty  casts  are  those  in  which  the  coagulated  material  forming 
the  molds  of  the  tubules  is  studded  with  oil  globules.  They  indicate 
fatty  degeneration  of  the  kidney  and  occur  in  chronic  parenchyma- 
tous nephritis. 

Granular  casts  are  made  up  of  coagulated  material  and  granular 
debris.     They  are  usually  observed  in  contracted  kidney. 

Hyaline  casts  or  mucous  casts,  are  transparent,  delicate  cylinders. 
They  may  occur  in  health,  but  are  always  observed  in  congestion 
or  inflammation  of  the  kidney. 


^, 


Fig.  38. — a.  Hyaline  cast;  b,  hyaline  cast 
with  a  few  attached  leukocytes;  c,  hyaline 
cast  with  attached  epithelium,  truly  an 
epithelial  cast.      (Landois.) 


Fig.  39. — Tubercle  bacilli  in 
urine.  Observe  tendency  to 
form  groups.  {Greene's  Med- 
ical Diagnosis.) 


Pus  casts  are  made  up  of  albuminous  material,  degenerated  leuko- 
cytes, and  bacteria,  and  are  indicative  of  renal  suppuration. 

Waxy  casts  are  large  and  yellowish  in  color,  and  give  the  amyloid 
reaction.     They  are  present  in  chronic  parenchymatous  nephritis. 

Cylindroids  resemble  hyaline  casts,  but  are  longer,  more  taper- 
ing and  constricted.     They  have  no  clinical  significance. 

To  examine  the  urine  for  tubercle  bacilli,  the  sediment  must  be 
thoroughly  centrifuged,  and  then  examined  in  the  same  way  that 
sputum  is  (see  page  467);  but  a  small  amount  of  egg  albumin  is 
added  to  the  specimen  before  it  is  placed  on  the  slide  or  coverslip. 

Spermatozoa  are  recognized  by  their  characteristic  form  and 
motility. 


326  CONGESTION   OF   THE   KIDNEYS 

DISEASES  OF  THE  KIDNEYS  AND 
BLADDER 

CONGESTION  OF  THE  KIDNEYS 

Synonyms. — Renal  hyperemia;  catarrhal  nephritis. 

Definition. — An  increase  in  the  amount  of  blood  in  the  vessels 
of  the  kidneys;  when  arterial,  it  is  termed  active  congestion;  when 
venous,  passive  congestion;  characterized  by  pain,  frequent  desire 
for  urination,  and  scanty,  high-colored  urine,  occasionally  containing 
albumin  or  blood. 

Causes. — Active:  cold;  irritating  substances  eliminated  by  the 
kidneys,  as  turpentine,  copaiba,  cantharides,  carbolic  acid,  nitrate 
or  chlorate  of  potassium;  the  eruptive  or  continued  fevers;  injuries 
over  the  kidneys;  pregnancy. 

Passive:  obstructive  diseases  of  the  heart  or  lungs,  pressure  of 
the  pregnant  uterus. 

Pathological  Anatomy. — The  kidneys  enlarge  and  increase  in 
weight;  redness  increases  (the  color  being  bluish  if  passive),  with 
points  of  vascularity,  corresponding  to  the  Malpighian  bodies,  and 
occasionally  minute  ecchymoses.  The  abnormal  hyperemia  causes 
a  catarrhal  state  of  the  ducts  of  the  pyramids,  with  shedding  of  their 
epithelium. 

If  mechanical  (passive)  obstruction  continues  for  some  time, 
increase  of  the  connective  tissue  with  consequent  induration  and 
contraction  results,  a  form  of  chronic  Bright's  disease. 

Symptoms. — Active  variety:  pain  over  kidneys  and  following  the 
course  of  the  ureters  into  the  testicles  and  penis,  irritable  bladder, 
almost  constant  and  pressing  desire  for  urination,  the  urine  scanty, 
high-colored,  and  occasionally  bloody,  with  fibrin,  casts,  and  albu- 
min; there  is,  as  a  rule,  no  pain  during  the  act  of  urination.  The 
constitutional  symptoms  are  headache,  slight  nausea,  vomiting, 
and  a  general  feeling  of  discomfort.  If  the  condition  persists,  inflam- 
mation of  the  kidney  results. 

Passive:  the  kidney  changes  are  marked  by  the  lung  or  heart 
trouble,  until  dropsy,  and  scanty  high-colored  albuminous  urine 
are  observed. 

Prognosis. — Active:  if  recognized  and  properly  treated,  favorable. 

Passive:  controlled  by  the  cause,  and  if  prolonged  terminating  in 
interstitial  nephritis. 


I 
ACUTE    PARENCHYMATOUS   NEPHRITIS  327 

Treatment. — The  most  important  indication  is  to  ascertain  and 
remove  the  cause.  Rest  in  bed  is  necessary.  Liquid  diet  and  saline 
purgatives  should  be  administered.  A  warm  bath,  diaphoretics, 
and  dry  or  wet  cups  over  the  loins  should  be  employed.  Infusion 
of  digitalis  and  bland  drinks  are  indicated.  Irritability  of  the  bladder 
may  be  relieved  by  camphor,  gr.  ij  to  iv  (0.13  to  0.26  gm.),  every 
four  hours,  alone  or  combined  with  morphine  sulphate,  gr.  }/{2  to  3^ 
(0.005  to  o.oii  gm.),  or  by  morphine  hypodermically. 

The  treatment  of  the  passive  form  resolves  itself  into  the  treat- 
ment of  the  cause,  remembering  that  there  is  too  much  blood  in  the 
veins  and  too  little  in  the  arteries.  There  are  three  ways  of  restoring 
the  circulation:  by  venesection,  opening  a  large  vein;  by  increasing 
the  power  of  the  heart  by  the  use  of  digitalis  or  strophanthus,  pref- 
erably the  first  named;  and  by  dilatation  of  the  capillaries  with  in- 
halations of  amyl  nitrite  or  the  internal  use  of  nitroglycerin  (i  per 
cent,  solution),  TTlj  to  iij  (0.06  to  0.18  c.c.)  every  four  hours.  The 
bowels  should  be  kept  open  by  salines. 

ACUTE  PARENCHYMATOUS  NEPHRITIS 

Synon3nns. — Acute  Bright's  disease;  acute  desquamative  nephritis; 
acute  tubal  nephritis;  acute  croupous  nephritis. 

Definition. — ^An  acute  inflammation  of  the  epithelium  of  the  urin- 
iferous  tubules,  characterized  by  fever,  scanty,  high-colored,  or 
smoky  urine,  dropsy,  with  more  or  less  constant  nervous  phenomena, 
the  result  of  acute  uremia. 

Causes. — Cold  and  exposure,  scarlatina,  diphtheria,  malaria, 
and  other  infectious  diseases,  traumatism  to  the  back,  pregnancy, 
and  the  persistent  use  of  irritants,  such  as  turpentine,  cantharides, 
phosphorus,  ginger,  etc.,  are  the  most  common  causes.  It  may  also 
be  associated  with  certain  skin  diseases,  extensive  burns  of  the  skin, 
and  simple  follicular  tonsillitis.  The  affection  is  most  frequent  in 
childhood. 

Pathological  Anatomy. — The  kidneys  are  generally  swollen,  en- 
gorged, more  vascular,  and  of  red  color;  in  the  second  stage  the  organ 
remains  large,  irregularly  red,  especially  the  tortex;  the  tubules 
are  engorged  and  filled  with  epithelium,  blood  corpuscles,  and  fibrin. 
The  capsule  is  easily  detached,  and  is  more  opaque  than  normal. 
If  the  termination  is  favorable  the  swelling  lessens,  the  vascularity 
diminishes,  and  the  tubules  gradually  return  to  their  normal  condition. 

Symptoms. — In  mild  cases,  slowly  developing  dropsy  with  anemia, 


328        ACUTE  PARENCHYMATOUS  NEPHRITIS 

shortness  of  breath  or  dyspnea,  and  weakness  are  the  only  symptoms, 
the  diagnosis  being  confirmed  by  the  results  of  urinary  examination. 
Usually,  however,  it  begins  suddenly  with  nausea,  violent  and  per- 
sistent vomiting,  fever,  and  dull  pain  over  the  kidneys,  following  the 
course  of  the  ureters.  There  is  a  frequent  desire  to  urinate,  and 
diarrhea,  harsh  and  dry  skin,  and  a  quick,  tense,  and  full  pulse  are 
present.  Dropsy  soon  appears,  beginning  first  in  the  eyelids  and 
face,  but  later  becoming  generalized.  Anemia  and  weakness  are 
marked  particularly  in  post-scarlatinal  cases.  Uremic  symptoms 
may  develop  at  any  time  during  the  attack.  The  affection  lasts  from 
one  to  four  weeks. 

The  urine  is  of  high  specific  gravity,  1025  to  1030,  scanty,  smoky 
(like  beef  washings)  in  color,  due  to  the  presence  of  blood.  Alburqin 
is  present  in  large  quantities,  and  the  microscope  reveals  hyaline, 
blood,  granular,  and  epithelial  casts  of  the  uriniferous  tubules,  blood 
corpuscles,  uric  acid,  urates,  oxalate  crystals,  and  epithelium.  The 
total  amount  of  urea  eliminated  during  the  twenty-four  hours  is 
lessened  from  one-fourth  to  one-half.  The  amount  of  phosphates 
and  chlorides  is  also  lessened. 

Complications. — Pericarditis,  pleurisy,  pneumonia,  peritonitis,  and 
uremia  are  the  principal  complications. 

Diagnosis. — The  diagnostic  features  of  this  disease  are  its  history, 
the  age  at  which  it  occurs,  the  sudden  onset,  the  dropsy,  and  the 
urine  which  is  scanty,  smoky,  and  of  high  specific  gravity,  containing 
albumin,  diminished  quantity  of  urea,  tube-casts  (hyaline,  blood, 
epithelium,  and  dark  granular  casts),  blood  cells,  epithelium,  and 
granular  cells. 

Prognosis. — The  prognosis  is  generally  favorable,  recovery  occur- 
ring inmost  cases  under  prompt  and  appropriate  treatment.  Uremia 
may,  however,  occur  in  the  course  of  the  disease  and  lead  to  a  fatal 
termination.  Pulmonary  edema,  purulent  exudations  into  the 
serous  cavities,  and  exhaustion,  may  intervene  and  produce  death. 
The  affection  may  pass  into  chronic  nephritis. 

Treatment. — The  patient  should  be  placed  at  rest  in  bed  until 
all  the  symptoms  have  disappeared.  A  strictly  milk  diet  is  most 
suitable,  but  if  the  depression  and  weakness  are  marked,  animal 
broths,  and  even  oysters  may  be  allowed.  Tea,  coffee,  beef-tea 
extracts,  and  stimulants  should  be  interdicted.  Water  or  cream  of 
tartar  lemonade  may  be  freely  used  for  its  diuretic  effect.  Dry 
cups  should  be  applied  over  the  kidneys,  followed  by  digitalis  or 


ACUTE  PARENCHYMATOUS  NEPHRITIS        329 

jaborandi  poultices,  using  equal  parts  of  flaxseed  and  the  leaves  of 
digitalis  or  jaborandi.  The  bowels  should  be  kept  freely  opened  by 
means  of  the  saline  cathartics,  compound  jalap  powder,  5  j  (4  gm.), 
in  water  before  breakfast,  or  elaterium,  gr.  }4  (o.oii  gm.),  repeated 
as  the  occasion  requires.  Combined  with  these  procedures  there 
should  be  free  sweating  or  diaphoresis.  This  is  best  obtained  by  the 
use  of  the  hot-air  bath,  the  hot  pack,  or  the  wet  sheet  and  blanket 
bath,  stimulating  the  peripheral  circulation  after  free  sweating  has 
occurred  by  rubbing  with  alcohol  and  water.  Drugs  may  be  admin- 
istered coincidently  to  aid  the  sweating  process.  Spirit  of  nitrous 
ether,  TTlv  to  xxx  (0.3  to  2  c.c),  fluidextract  of  pilocarpine,  TTtv  to 
XXX  (0.3  to  2  c.c),  every  three  or  four  hours,  pilocarpine 
hydrochloride,  gr.  3^^  (o.oii  gm.),  hypodermically,  as  the  occasion 
requires,  or  the  wine  of  ipecac,  Tflj  to  iij  (0.06  to  0.2  c.c),  every  half- 
hour  may  be  used  for  this  purpose.  Diuretics,  such  as  digitalis, 
digitalin,  gr.  ^foo  (0.00065  g^i-)?  citrated  caffeine,  gr.  ij  to  iv  (0.13  to 
0.26  gm.),  or  sparteine  sulphate,  gr.  }i  to  }y^  (0.02  to  0.03  gm.) 
should  be  employed.  The  following  formula  (Millard)  is  suitable 
in  the  majority  of  cases: 

I^,     Tinct.  digitalis f  Bss  15  c.c. 

Aceti  scillas f  §jss  45  c.c. 

Spt.  ^theris  nitrosi f  §ij  60  c.c. 

M.  S. — Teaspoonful  every  two  to  four  hours,  in  water. 

The  following  combination  has  also  given  excellent  results: 

I^.     Potassii  acetat 5iv  15  gm. 

Inf.  digital f  Siij  90  c.c. 

Liq.  potassii  citratis f  §iij  90  c.c. 

M.  S. — Tablespoonful  every  two  to  four  hours,  in  water. 

Tyson  strongly  urges  the  use  of  infusion  of  digitalis  instead  of  the 
tincture.  He  also  recommends,  as  an  admirable  diuretic  combina- 
tion,  Trousseau's   diuretic  wine,   viz.: 

I^.      Junip.  contus 5x  40  gm. 

Pulv.  digitalis 5ij  8  gm. 

Pulv.  scillas 5j  4  gm. 

Vin.  xerici Oj  480  c.c. 

Macerate  for  four  days  and  add 

Potassii  acetatis 5  iij  12  gm. 

Express  and  filter. 

S. — Tablespoonful  three  times  a  day  for  an  adult. 


330  CHRONIC   PARENCHYMATOUS   NEPHRITIS 

The  onset  of  uremia  (page  345)  calls  for  special  treatment. 

As  soon  as  the  blood  disappears  from  the  urine  some  preparation 
of  iron,  preferably  Basham's  mixture,  should  be  administered  until 
the  health  is  entirely  restored.  The  addition  of  i  minim  (0.065  c.c.) 
of  spirit  of  nitroglycerin  to  each  dose  of  Basham's  mixture  increases 
its  efficiency. 

I^.     Liq.  ammon.  acetat f  5vj  180  c.c. 

Acid,  acetic f  5iij  12  c.c. 

Tinct.  ferri  chlor f  5v  20  c.c. 

Alcoholis f  Bij  60  c.c. 

Syrup f  Biv  120  c.c. 

Aquae f  Biv  120  c.c. 

M.  S. — Basham's  mixture.     Dose  i  dram  to  i  ounce,  diluted. 

CHRONIC  PARENCHYMATOUS  NEPHRITIS 

Sjnionyms. — Chronic  Bright's  disease;  chronic  croupous  nephritis; 
chronic  tubal  nephritis;  chronic  albuminuria;  large  white  kidney. 

Definition. — A  chronic  inflammation  of  the  cortical  tubular  struc- 
ture of  the  kidneys;  characterized  by  albuminous  urine,  dropsy,  and 
increasing  anemia,  with  attacks  of  acute  uremia. 

Causes. — It  rarely  follows  an  acute  attack;  in  the  majority  of 
cases  it  is  subacute  or  chronic  from  the  onset.  It  is  a  disease  of 
young  adults,  especially  males,  and  is  seldom  observed  after  forty 
years  of  age.  Habitual  exposure  to  cold" and  wet,  malaria,  syphilis, 
alcoholic  excesses,  chronic  mercurialism,  lead-poisoning,  opium 
habit,  protracted  suppuration,  phthisis,  hepatic  disorders,  pregnancy, 
and  some  undetermined  nervous  condition  are  the  principal  causes. 

Pathological  Anatomy. — The  kidney  is  large,  often  twice  its 
natural  size,  smooth,  and  white  or  yellowish-white  in  color.  The 
capsule  is  nowhere  adherent  to  the  organ.  Upon  section,  consider- 
able tumefaction  of  the  cortical  substance  and  rarity  of  vascular 
striae  are  recognized.  The  medullary  substance  shows  no  appreci- 
able alteration,  its  color  being  normal.  The  convoluted  tubes  are 
irregularly  dilated  and  thickened,  and  filled  with  broken-down 
granulated  epithelium  and  fibrinous  casts.  In  pronounced  cases 
there  is  fatty  degeneration  of  the  tubular  epithelium.  The  intertubu- 
lar  matrix  is  greatly  thickened — a  change  due  to  hyperplasia  of  the 
connective-tissue  elements,  to  the  migration  of  the  white  corpuscles 
and  their  subsequent  multipUcation  and  fatty  transformation,  and  to 


CHRONIC   PARENCHYMATOUS   NEPHRITIS  33 1 

a  quantity  of  fluid  exudation,  the  product  of  the  increased  pressure 
in  the  veins.  As  the  affection  progresses  the  connective  tissue  tends 
to  undergo  contraction,  and  the  organ  becomes  pale  and  reduced  in 
size,  the  capsule  becomes  more  or  less  adherent,  and  the  surface  of 
the  kidney  becomes  uneven.  During  this  contracting  stage  small 
hemorrhages  may  appear,  scattered  throughout  the  cortex. 

Symptoms. — The  onset  of  the  disease  is  gradual  and  insidious, 
being  marked  by  a  period  of  ill-health,  anemia,  digestive  disturb- 
ances, weakness,  puffiness  under  the  eyes,  most  noticeable  in  the 
morning,   dyspnea,   cardiac  palpitation,   etc. 

Vomiting,  without  apparent  cause,  headache,  vertigo,  defective 
vision,  and  more  or  less  generalized  dropsy  are  also  symptoms. 
Transient  blindness  is  not  uncommon  in  the  early  stages,  but  late 
in  its  course  permanent  loss  of  vision  may  occur,  due  to  retinal 
disease.  Hypertrophy  of  the  heart',  with  high  arterial  tension  and 
accentuation  of  the  aortic  second  sound  are  common  accompani- 
ments. Bronchial  catarrh,  with  edema  of  the  larynx,  may  also 
develop.  Anemia  is  pronounced  on  account  of  the  large  loss  of 
albumin  and  gastrointestinal  disorders,  and  neuralgic  pains  are  com- 
mon. Uremic  asthma  and  other  manifestations  of  uremia  may 
present  themselves  at  any  time.  Irritability  of  the  bladder  is  a 
very  constant  symptom,  occurring  very  early  in  the  course  of  the 
disease. 

The  Urine. — The  urine  is  scanty,  high-colored,  albuminous,  and 
under  the  microscope  shows  hyaline  and  granular  tube-casts,  granular 
epithelium,  and  if  fatty  degeneration  occur,  fatty  tube-casts  and  oil* 
globules.  The  increase  above  the  normal  amount  of  the  urine,  as 
the  disease  progresses,  must  not  be  forgotten  when  the  specific 
gravity  is  low,  1.010-1.015,  and  the  quantity  of  albumin  is  increased. 
The  normal  constituents  of  the  urine,  and  particularly  urea  are 
diminished.     In  the  hemorrhagic  form,  blood  is  present  in  the  urine. 

Complications. — Uremia,  edema  of  the  lungs,  pneumonia,  pleurisy, 
pericarditis,  peritonitis,  meningitis,  cardiac  hypertrophy,  and  apo- 
plexy are  the  most  common  complications. 

Prognosis. — Complete  recovery  never  occurs.  Well-marked  cases 
may  terminate  in  death  within  a  few  months  or  two  years,  while 
milder  cases  under  appropriate  treatment  may  be  prolonged  for  an 
indefinite  period.  The  appearance  of  complications  and  acute 
exacerbations  are  of  unfavorable  significance.  The  presence,  per- 
sistently, of  fatty  tube-casts  and  oil  globules  in  the  urine  is  likewise 


332  CHRONIC   PARENCHYMATOUS    NEPHRITIS 

unfavorable.  The  secondary  contraction  of  the  kidneys  must  always 
be  kept  in  mind,  the  particular  symptoms  of  which  are  increased 
flow  of  urine  of  low  specific  gravity,  with  small  amount  of  albumin, 
and  hypertrophy  of  left  ventricle,  with  accentuated  aortic  second 
sound.  It  is  to  be  borne  in  mind  that  the  course  of  a  case  of  chronic 
Bright 's  disease  is  not  continuously  downward;  periods  of  remission 
often  follow  the  most  aggravated  symptoms,  the  patient  and  his 
friends  being  buoyed  with  the  hope  of  an  early  recovery,  when, 
suddenly,  an  attack  of  acute  uremia  terminates  life. 

Treatment. — Rest  is  the  first  indication  in  the  treatment.  Resi- 
dence in  a  dry  and  warm  climate  is  a  very  useful  adjunct.  Woolen 
underclothing  should  be  worn.  The  diet  is  of  prime  importance 
and  should  be  so  arranged  as  to  reduce  the  quantity  of  nitrogenous 
foods  to  a  minimum.  It  ma}^  consist  of  an  absolute  milk  regimen, 
pure,  or  prepared  as  the  patient  'fi.nds  it  most  palatable,  or  an  exclu- 
sive lean  meat  diet,  prepared  by  finely  chopping,  removing  all  fibrous 
and  fatty  portions,  boiled  quickly,  salted  to  taste,  and  served  hot — 
the  so-called  ''Salisbury  steaks."  The  use  of  half  a  pint  of  hot 
water,  acidulated  with  lemon,  before  each  meal  is  valuable. 

The  elimination  of  the  effete  matters,  retained  in  the  blood  by 
reason  of  the  crippled  condition  of  the  kidneys,  may  be  brought 
about  by  catharsis,  diuresis,  and  diaphoresis.  The  use  of  cathartics 
aids  in  reducing  any  existing  edema  and  prevents  to  some  extent 
the  onset  of  uremia.  The  following  is  of  value  when  the  urine  is 
scanty  and  the  bowels  are  costive: 

I^.     Hydrargyri  chlor.  mitis, 
Pulv.  scill^, 

Pulv.  digital aa  gr.  j  aa   0.065  gm. 

M.     Ft.  pil.  No.  i. 

S. — To  be  taken  three  times  daily. 

Excessive  dropsy  will  call  for  the  administration  of  compound 
jalap  powder,  magnesium  sulphate,  elaterium,  or  the  alkaline  mineral 
waters  combined  with  free  diaphoresis.  When  the  urine  is  scanty, 
diuretics  are  of  value;  the  most  useful  are  digitalis,  citrated  caffeine, 
sparteine  sulphate,  nitroglycerin,  potassium  citrate,  diuretin,  and 
water.  Dry  cups  or  poultices  over  the  loins,  and  the  injection  of 
normal  salt  solution  into  the  bowels  or  beneath  the  skin  have  diuretic 
properties.  Diaphoresis  may  be  brought  about  by  the  use  of  the 
warm  bath,  the  Turkish  bath,  the  warm  pack,  and  vapor  or  hot-air 


CHRONIC    INTERSTITIAL   NEPHRITIS  333 

bath  together  with  friction  and  the  administration  of  pilocarpine  in 
some  form.     The  following  ointment  is  extremely  valuable: 

^.      Pilocarpinae  nitrat gr.  j  to  iij  0.065  to  2  gm. 

Petrolati §  j  30.0  gm. 

M.  S. — Apply  a  piece  the  size  of  a  hickory-nut  over  the  dorso- 
lumbar  regions,  night  and  morning,  covering  the  surface  with  a 
layer  of  cotton  or  gauze. 

The  anemia  requires  the  administration  of  some  preparation  of 
iron,  the  best  of  which  for  this  condition  is  Basham's  mixture  on 
account  of  its  diuretic  properties.  The  addition  of  the  spirit  of 
nitroglycerin  adds  to  its  efficacy.  Cod-liver  oil  and  arsenic  are 
also  of  benefit.  Drugs  such  as  ergot,  quinine,  gallic  acid,  sodium 
benzoate,  tincture  of  cantharides,  and  potassium  iodide  are  believed 
to  exercise  an  influence  in  checking  the  waste  of  albumin  and  are 
sometimes  employed. 

When  the  dropsy  becomes  marked  the  various  measures  already 
mentioned  should  be  freely  employed  and  often  it  will  be  necessary 
to  resort  to  tapping  and  to  multiple  punctures  of  the  skin.  Uremia 
(see  page  345)  will  demand  special  treatment. 

Surgical  Treatment. — Edebohls  proposed  and  employed  decap- 
sulation or  decortication  of  the  kidney  in  this  disease  with  encourag- 
ing results. 

CHRONIC  INTERSTITIAL  NEPHRITIS 

Synonyms. — Chronic  Bright 's  disease;  sclerosis  of  the  kidney; 
contracted  kidney;  cirrhotic  kidney;  granular  kidney;  small  red 
kidney;  gouty  kidney. 

Definition. — An  inflammation  of  the  intervening  connective  tissue 
of  the  kidney,  chronic  in  its  progress,  resulting  in  an  induration  or 
hardening,  with  contraction  of  the  organ;  characterized  by  the  fre- 
quent voiding  of  large  amounts  of  pale,  albuminous  urine,  of  low 
specific  gravity,  disorders  of  the  gastrointestinal  canal  and  nervous 
system,  and  a  strong  tendency  to  cardiac  hypertrophy  and  changes 
in  the  blood-vessels.     Albuminuria  may  be  absent. 

Causes. — The  disease  occurs  usually  in  males  from  forty  to  sixty 
years  of  age.  It  may  be  primary,  or  secondary  to  chronic  parenchy- 
matous nephritis.  Gout,  chronic  lead-poisoning,  syphilis,  alcoholism, 
opium   habit;   chronic   cystitis,   chronic   gonorrhea,   long-continued 


334  CHRONIC   INTERSTITIAL   NEPHEITIS 

worry,  anxiety  or  grief,  alterations  in  the  renal  ganglionic  centers, 
hereditary  influences,  passive  congestion  from  heart-disease,  and 
hepatic  disorders  are  the  principal  causes. 

Pathological  Anatomy. — Both  kidneys  are  usually  involved  and 
their  size  is  diminished.  The  capsule  is  thickened,  opaque,  and 
adherent.  The  surface  of  the  kidney  is  granular,  with  cysts  of 
various  sizes,  of  transparent  color,  scattered  irregularly  over  the 
surface.  On  section,  the  tissue  of  the  kidney  is  tough  and  resistant. 
The  cortical  portion  is  thin  from  atrophy,  being  only  a  line  or  two  in 
thickness.  The  connective  tissue  is  greatly  thickened,  compressing 
the  tubules  into  mere  threads,  the  glomeruli  being  grouped  together 
in  bunches,  owing  to  the  wasting  of  the  intermediate  tubes.  The 
color  varies  from  a  dark  brown  to  a  yellowish  gray,  according  to 
the  amount  of  blood  in  the  organ. 

The  left  side  of  the  heart  is  hypertrophied,  and  there  is  also  hyper- 
trophy of  the  muscular  fiber  of  the  arterioles  throughout  the  body; 
if  the  case  is  protracted,  the  hypertrophied  tissues  undergo  fatty 
degeneration.  Cardiac  degeneration  with  arteriocapillary  sclerosis 
or  fibrosis  is  associated  with  advanced  nephritis.  The  changes  in 
the  arterial  walls  lead  to  apoplexy,  albiiminuric  retinitis,  and  fatty 
degeneration  and  atrophy  of  the  ganglionic  centers. 

According  to  Tyson,  the  kidney  may  be  atrophic  and  possess  an 
excess  of  connective  tissue  as  the  result  of  seniHty,  independent  of 
chronic  interstitial  nephritis. 

Sjnnptoms. — The  onset  is  insidious,  and  often  marked  alterations 
in  the  kidneys,  heart,  and  vessels  have  occurred  before  the  disease  is 
recognized.  There  are  no  characteristic  early  symptoms  in  the 
majority  of  cases,  the  disease  being  apparently  latent  until  some 
special  outbreak  causes  a  more  thorough  examination  of  the  patient, 
when  interstitial  nephritis  is  detected. 

Any  of  the  following  symptoms  may  first  attract  attention: 
frequent  micturition;  increased  amount  of  acid  urine,  50  to  90  ounces, 
and  of  a  pale  color;  low  specific  gravity,  1005  to  1015;  containing 
a  small  amount  of  albumin,  which  may  be  absent  for  days;  occasional 
epithelial  cells  and  hyaline  and  pale  granular  casts.  No  dropsy,  but 
a  little  puffiness  and  edema  of  the  conjunctiva — the  Bright's  eye. 
Subconjunctival  ecchymoses.  Disorders  of  vision.  Albuminuric 
retinitis.  Forcible  cardiac  action  with  high  arterial  tension,  due  to 
left  cardiac  hypertrophy,  which  is  an  almost  constant  condition. 
Attacks  of  vertigo;  headache;  pulsations  in  the  neck,  and  other 


CHRONIC   INTERSTITIAL   NEPHRITIS  335 

parts  of  the  body,  and,  as  the  disease  progresses,  cardiac  distress, 
dyspnea,  and  palpitation  occur.  A  redupHcation  of  the  first  cardiac 
sound  is  common;  the  second  aortic  sound  is  accentuated  and  the 
pulse  is  hard  and  resisting,4ndicating  high  tension  and  thickening. 

Progressive  anemia  is  a  frequent  symptom.  There  is  great 
weakness;  the  body  weight  declines;  the  skin  is  dry  and  scurfy; 
and  there  is  shortness  of  breath  on  exertion.  Albumin  may  be  con- 
stantly absent  from  the  urine,  and  casts  be  only  occasionally  detected 
after  many  trials  and  yet  the  disease  will  progress  toward  a  fatal 
termination.  Toward  the  end,  the  urine  diminishes  in  quantity, 
the  specific  gravity  increases,  and  the  casts  become  more  numerous 
and  various,  dark  granular  and  blood  casts  often  being  observed. 
Uremia  may  occur  at  any  time  and  may  be  manifested  by  persistent 
dyspepsia,  occasional  vomiting,  headache,  vertigo,  stupor,  drowsi- 
ness, violentr  itching  of  the  skin,  tremors,  convulsions,  epileptic 
seizures,  or  apoplectic  attacks.  The  duration  is  indefinite  and  the 
termination  is  usually  in  death  by  convulsions  and  coma. 

Complications. — Bronchitis,  pneumonia,  pleurisy,  pericarditis,  car- 
diac hypertrophy,  uremia,  albuminuric  retinitis,  and  apoplexy,  are 
the  most  common  complications. 

Diagnosis. — Interstitial  nephritis  is  most  likely  to  be  confounded 
with  parenchymatous  nephritis.  The  following  table  from  Wheeler 
and  Jack  presents  the  most  important  points  of  difference  between 
the  various  forms  of  Bright's  disease: 


33^ 


CHRONIC   INTERSTITIAL   NEPHRITIS 


CHRONIC    INTERSTITIAL   NEPHRITIS 


337 


It  is  important,  also,  to  distinguish  between:  (i)  interstitial  neph- 
ritis with  secondary  arterial  sclerosis,  and  (2)  general  arterial  sclero- 
sis with  secondary  contracted  kidney.  Tyson  thus  tabulates  the 
differences  between  these  two  conditions: 


Primary  chronic   interstitial  nephritis 


Primary  general  arteriosclerosis 


1.  Causes  of  chronic  interstitial  nephritis, 
such  as  overeating  and  drinking,  gout, 
diabetes,    syphilis,    lead   intoxication,    etc. 

2.  Characteristic  insidious  onset,  including 
digestive  derangements,  small  albuminuria, 
few  casts,  with  little  or  no  evidence  of 
arterial  change  at  first. 

3.  Edema,  never  at  first,  later  unusual 

4.  Arterial  pulsation  often  very  annoying..  .  . 

5.  Vertigo  infrequent 

6.  Albuminuric  retinitis  and  hemorrhages 
into  retina. 

7.  Hypertrophy  of  one  or  both  ventricles 
rather  more  frequent,  say  42  per  cent. 

8.  High  blood-pressure  and  high  arterial 
tension  before  vascular  change  is  evident. 

0.   True  uremia 


1.  Same  causes. 

2.  Early  appearance  of  arterial  changes. 


3.  Edema  frequent  and  often  marked. 

4.  No  pulsation  in  head  or  elsewhere. 

5.  Vertigo  common. 

6.  Retinal     changes,     but     n9t    hemor- 
rhage, nor  retinitis  albuminurica. 

7.  Rather  less  frequent,  say  36  per  cent. 

8.  Moderate  or  lowered  blood-pressure, 
moderate  arterial  tension. 

9.  Simulated  uremia. 


Prognosis. — Recovery  never  occurs.  The  disease  is  essentially 
chronic;  cases  have  lasted  as  long  as  eleven  years.  Liability  to  death 
from  cerebral  hemorrhage  must  be  remembered.  Uremic  symp- 
toms are  of  unfavorable  significance. 

Treatment. — The  diet  should  be  carefully  regulated  and  nitrog- 
enous foods  should  be  eliminated.  Milk  (plain,  skimmed,  or  diluted 
with  Vichy),  eggs  (soft-boiled  or  poached  in  milk),  chicken  broth, 
and  vegetables  should  constitute  the  larger  portion  of  the  food. 
Alcoholic  stimulants  should  be  avoided.  Physical  and  mental  rest 
should  be  advised.  A  daily  warm  or  hot  bath  is  valuable  but  under 
no  consideration  should  cold  or  sea-bathing  be  allowed.  Warm 
clothing  should  be  worn  and  the  body  should  be  protected  from  cold 
and  dampness.  Regularity  in  the  bowel  movements  is  desirable 
and  for  this  purpose  the  alkaline  mineral  waters,  the  salines,  or 
cascara  sagrada  should  be  administered.  Iron  will  be  necessary  to 
combat  the  anemia  and  potassium  iodide  may  be  of  value  in  lessening 
the  connective-tissue  hypertrophy.  Headache,  vertigo,  and  similar 
symptoms  dependent  upon  increased  arterial  tension  may  be  relieved 
by  the  use  of  spirit  of  nitroglycerin,  TTlj  (0.06  c.c),  or  nitroglycerin, 
gr.  Koo  (0.00065  g^-)j  three  times  daily.  Opium  or  any  of  its 
preparations  should  never  be  employed.  When  a  hypnotic  is  re- 
quired, sulphonal,  trional,  or  paraldehyde  should  be  used.  In  the 
22 


33 8  *    AMYLOID   KIDNEY 

early  stages  of  the  disease  the  following  formula  will  be  found  very- 
valuable  : 

I^.     Hydrargyri  chloridi  corrosiv  gr.j.  0.065  g^^- 

Auri  et  sodii  chloridi gr.  j  0.065  gm. 

Ferri  reduct gr.  xxx  2  .  o      gm. 

Spt.  glonoini TUxxx  2  .  o      c.c. 

M.     Ft.  pil.  No.  xxx. 

S. — One  after  meals. 

For  gastric  symptoms  the  following  is  an  excellent  formula: 

I^.     Pepsin,  pur gr.  xxxij  2  gm. 

Acidi  hydrochloric,  dil. . . , .   f  §ss  15  c.c. 

Glycerini f 5j  30  c.c. 

Aquae  chloroform! .  q.  s.  ad  f  Biij  90  c.c. 

M.  S. — One  teaspoonful  at  mealtime,  well  diluted. 

AMYLOID  KIDNEY 

Sjnionyins. — Chronic  Bright's  disease;  waxy  kidney;  lardaceous 
kidney. 

Definition. — A  peculiar  infiltration  into  the  structure  of  the  kidney, 
from  the  deposit  of  an  albuminoid  material,  having  a  superficial 
resemblance  to  molten  wax  or  boiled  starch,  and  which  strikes  a 
deep  mahogany-red  color  when  treated  with  a  solution  of  iodine. 
Similar  changes  occur  in  the  liver,  spleen,  intestines,  and  other  organs. 

Causes. — The  chief  causes  are  prolonged  suppuration,  especially 
of  the  bones;  coxalgia;  syphilis;  cancer;  phthisis. 

Pathological  Anatomy. — The  kidney  is  uniformly  enlarged.  It 
presents  a  pale,  ghstening,  translucent  appearance,  and  has  a  doughy 
consistency.  On  section,  the  surface  is  homogeneous,  anemic,  and 
whitish.  The  deposit  occurs  along  the  renal  vessels  and  in  the  vas- 
cular tufts  of  the  glomeruli,  progressing  until  all  parts  of  the  organ 
are  infiltrated.  When  the  organ  is  thus  infiltrated,  the  structure 
proper  undergoes  an  atrophic  degeneration,  the  result  of  pressure. 

The  reaction  with  iodine  and  sulphuric  acid  affords  a  certain  test 
for  the  amyloid  deposit.  Brush  over  a  section  of  the  affected  kidney 
a  solution  of  iodine  with  iodide  of  potassium  in  water,  when  a  mahog- 
any color  will  be  produced,  and  if  diluted  sulphuric  acid  is  now  added 
a  violet  or  bluish  tint  results.  A  very  pretty  reaction  is  made  by 
contact  with  a  i  per  cent,  solution  of  aniHne  violet,  which  strikes  a 


PYELITIS  339 

red  or  pink  color  with  the  amyloid  material,  while  the  unaltered 
tissues  are  stained  blue,  making  a  beautiful  contrast. 

Similar  changes  occur  in  other  organs  of  the  body.  With  the  amy- 
loid change  may  be  associated  either  parenchymatous  or  interstitial 
nephritis. 

Symptoms. — Together  with  the  symptoms  of  the  underlying 
causes  there  are  edema  of  the  lower  extremities,  ascites,  increased 
flow  of  pale  watery  urine  of  low  specific  gravity  containing  albumin 
and  hyaline  and  waxy  tube-casts,  and  sometimes  diarrhea.  The 
liver  and  spleen  are  enlarged.  Uremia,  cardiac  hypertrophy,  or 
increased  arterial  tension  are  extremely  rare  in  this  disease  unless 
other  forms  of  nephritis  are  present  coincidently. 

Diagnosis. — The  history  of  prolonged  suppuration,  the  enlarge- 
ment of  the  liver  and  spleen,  and  the  increased  flow  of  pale  urine 
containing  waxy  casts  which  give  the  amyloid  reaction,  serve  to 
distinguish  this  disease  from  other  renal  affections. 

Prognosis. — If  the  underlying  disease  can  be  cured  before  the 
amyloid  change  has  been  fully  developed  it  may  be  arrested;  other- 
wise a  fatal  termination  may  be  expected  in  from  a  few  months  to  a 
year. 

Treatment. — In  addition  to  measures  directed  toward  the  primary 
cause,  every  effort  should  be  made  to  sustain  the  patient.  For  this 
purpose  a  generous  diet,  syrup  of  iodide  of  iron,  cod-liver  oil,  quinine, 
ammonium  chloride,  etc.,  should  be  freely  administered.  In  cases 
due  to  syphilis,  potassium  iodide  and  small  doses  of  bichloride  of 
mercury,  gr.  >^o  to  ^5  (0.0015  to  0.003  gm.),  should  be  given  over 
an  extended  period. 

PYELITIS 

Definition. — Pyelitis  is  acute  catarrhal  inflammation  of  the  pelvis 
of  the  kidney;  the  term  pyelonephritis  is  used  when  the  inflammation 
extends  to  the  substance  of  the  kidney.  In  pyonephrosis  there  is  an 
accumulation  of  pus  in  the  pelvis  of  the  kidney  due  to  the  ureter 
being  blocked  and  the  pus  being  unable  to  escape.  Pyelonephritis  is 
practically  a  combination  of  pyelitis  and  nephritis ;  and  pyonephrosis  is 
sometimes  known  as  suppurative  nephritis  or  surgical  kidney.  The 
disease  is  characterized  by  lumbar  pains,  irritability  of  the  bladder, 
the  urine  being  neutral  or  alkahne  in  reaction  and  milky  in  appear- 
ance; if  pyonephrosis  occurs  symptoms  of  hectic  fever  and  exhaus- 
tion are  added,  the  urine  containing  pus. 


340  PYELITIS 

Causes. — Cold  or  exposure;  cystitis;  obstruction  of  the  ureters  by 
renal  calculi;  pressure  from  a  tumor;  prolonged  use  of  bromides  and 
other  irritative  drugs;  rheumatism;  and  infectious  diseases.  The 
Bacillus  coli  communis  is  the  organism  most  frequently  present  in 
pyelonephritis;  but  other  organisms  may  be  responsible  for  the 
condition. 

Pathological  Anatomy. — The  inflammation  is  at  first  catarrhal; 

» 

it  is  characterized  by  injection  of  the  mucous  membrane  of  the  pelvis 
of  the  kidney,  with  slight  extravasations  of  blood;  relaxation  and 
softening,  shedding  of  the  epithelium,  and  the  subsequent  discharge 
of  mucus  and  pus.  If  the  morbid  condition  has  existed  for  some  time, 
the  kidneys,  one  or  both,  are  in  a  process  of  suppuration;  they  are 
enlarged,  deeply  congested,  except  where  suppuration  is  proceeding, 
when  they  are  of  a  yellowish-white  color — pyelonephritis.  Pus  is 
constantly  forming  and,  if  there  be  no  obstruction,  flows  away  with 
the  urine;  should  there  be  an  impediment  to  its  escape,  pus  accumu- 
lates in  the  pelvis  of  the  kidney,  causing  its  distention,  giving  rise 
to  the  condition  known  as  pyonephrosis.  The  pressure  caused  by 
the  obstruction  finally  leads  to  destruction  of  the  entire  organ,  a 
mere  sac,  or  renal  cyst,  remaining. 

Symptoms. — The  affection  begins  with  chilliness,  feverishness, 
lumbar  pains  following  the  course  of  the  ureters,  and  frequent 
micturition.  The  urine  is  milky  in  appearance  when  voided,  acid 
or  neutral  in  reaction,  and  deposits  a  copious  whitish  or  yellowish - 
white  sediment  containing  a  small  amount  of  albumin.  Blood  will 
be  present  if  the  condition  is  due  to  a  renal  calculus.  The  formation 
of  pus  is  indicated  by  chills,  irregular  fever,  sweats,  localized  pain, 
enlargement,  and  tenderness  in  lumbar  region,  the  presence  of  pus 
in  the  urine,  and  leukocytosis.  In  marked  cases  there  are  low  mutter- 
ing deHrium,  fissured  and  dry  tongue,  anemia,  emaciation,  stupor, 
and  coma.  If  both  kidneys  are  involved  uremia  may  supervene. 
PyeUtis  should  be  thought  of  as  a  possible  cause  of  fever  in  infants 
and  children,  where  no  obvious  cause  is  found. 

Diagnosis. — Cystitis  may  be  distinguished  by  its  history,  the 
absence  of  lumbar  pains,  and  the  alkaline  urine. 

Perinephritic  abscess  or  suppuration  of  the  loose  cellular  tissue 
surrounding  the  kidney,  is  characterized  by  localized  pain,  swelling, 
tenderness,  and  edema  in  the  lumbar  region  with  chills,  fever,  and 
sweat,  but  the  urine  remains  normal. 

Renal  calculus  may  give  rise  to  pyelitis  and  in  such  cases  renal 


NEPHROLITHIASIS  34 1 

colic,  the  passage  of  the  stone,  and  the  presence  of  blood  in  the  urine 
will  aid  in  making  the  diagnosis. 

Tuberculosis  of  the  pelvis  of  the  kidney  has  many  points  in  com- 
mon with  simple  pyelitis,  but  in  the  former  there  are  in  addition 
tuberculous  foci  elsewhere  in  the  body  and  tubercle  bacilli  may  be 
found  in  the  urine. 

Prognosis. — Simple  catarrhal  cases  in  which  there  is  no  obstruction 
to  the  discharge  usually  recover.     In  the  presence  of  an  obstruction* 
or  suppuration  the  prognosis  is  unfavorable. 

Treatment. — Rest  in  bed  and  a  milk  diet  are  essential.  Free 
diaphoresis  and  the  free  consumption  of  water  to  dilute  the  urine 
are  indicated.  Local  applications  of  heat  to  the  lumbar  region 
and  the  use  of  opium  will  be  required  to  relieve  the  pain.  The  charac- 
ter of  the  renal  secretion  may  be  altered  by  the  administration  of 
tar,  santal  wood  oil,  copaiba,  eucalyptol,  turpentine,  cubebs,  benzoic 
acid,  salol,  or  urotropine.  Of  these  benzoic  acid,  5  gr.  (0.33  gm.), 
may  be  given  in  capsules  four  times  a  day;  or  urotropine  also  in  cap- 
sules, and  in  similar  dose,  and  preferably  on  an  empty  stomach.  If 
there  is  renal  hemorrhage 'alum,  gr.  xx  (1.3  gm.),  may  be  used.  The 
rapid  exhaustion  calls  for  the  use  of  tonics,  particularly  quinine, 
strychnine,  iron,  etc.  As  suppuration  is  likely  to  supervene  at  any 
time,  a  surgeon  should  be  consulted  early  as  a  prompt  operation 
may  be  the  means  of  saving  otherwise  hopeless  cases. 

NEPHROLITHIASIS 

Synonyms. — Renal  calculus;  gravel;  renal  colic;  stone  in  the 
kidney. 

Definition. — Renal  calculi  are  concretions  formed  by  the  precipi- 
tation of  certain  substances  from  the  urine,  around  some  body  or 
substance  acting  as  a  nucleus. 

Their  presence  may  not  be  recognized  until  one  or  more  attempt 
to  pass  along  the  ureters,  when  an  attack  of  renal  colic  results; 
or,  by  irritation  pyelitis  is  produced;  or,  more  rarely,  they  are  voided 
by  the  urine  without  exciting  any  symptoms.  By  gravel  is  meant 
very  small  concretions  (sand),  which  are  often  passed  in  the  urine  in 
large  numbers. 

Causes. — The  affection  occurs  at  all  ages,  but  is  most  common  in 
individuals  from  forty  to  fifty  years  of  age.  A  special  liability  seems 
to  exist  in  some  families  but  the  precise  etiology  of  nephroUthiasis 


342  NEPHROLITHIASIS 

is  as  yet  undetermined.     A  sedentary  life  and  overindulgence  in  food 
and  alcohol  are  said  to  be  predisposing  factors. 

Characteristics. — In  structure  a  urinary  calculus  consists  of  a 
central  nucleus  surrounded  by  a  body,  outside  of  which  there  may  be 
a  phosphatic  crust.  The  nucleus  may  or  may  not  be  of  the  same 
material  as  the  rest  of  the  stone,  sometimes  being  a  foreign  body, 
or  inspissated  mucus  or  blood.  On  section  the  stone  shows  a  strati- 
fied arrangement,  often  radiated.     They  occur  in  several  varieties: 

1.  Uric  acid,  as  calculi  and  gravel,  and  especially  associated  with 
the  gouty  diathesis. 

2.  Urates,  chiefly  urate  of  ammonium;  nearly  always  in  childhood. 

3.  Oxalate  of  lime  or  mulberry  calculus;  characterized  by  hardness, 
roughness,  and  very  dark  color. 

4.  Phosphatic  calculi  form  as  frequently  in  the  bladder  as  in  the 
kidney,  and  present  a  chalky  or  earthy  appearance. 

5.  Alternating  calculi,  consisting  of  alternate  layers  of  two  or  more 
primary  deposits. 

Symptoms. — In  the  absence  of  renal  colic  there  are  usually  no 
symptoms  to  attract  the  attention.  Renal  colic  is  manifested 
chiefly  by  agonizing  pain  in  the  back,  principally  in  the  dorso-lumbar 
region,  which  radiates  along  the  ureters  and  is  worse  on  motion, 
attended  by  retraction  of  the  testicle  on  the  corresponding  side, 
irritability  of  the  bladder,  pallor  of  the  face,  pinched  features,  nausea, 
vomiting,  lowering  of  surface  temperature,  faintness  and  rarely  un- 
consciousness. The  paroxysm  terminates  suddenly  after  some  min- 
utes or  a  few  hours,  the  stone  escaping  into  the  bladder.  If  the  stone 
is  not  passed  the  attack  may  subside  to  recur  within  a  short  period. 
The  urine  is  more  or  less  suppressed,  usually  escaping  in  drops  and 
stained  with  blood.  If  the  condition  is  bilateral  and  both  ureters 
are  obstructed,  uremic  symptoms  occur.  This  is  rare.  Obstruction 
of  the  ureter  by  a  calculus,  if  unrelieved,  may  terminate  in  pyelitis, 
hydronephrosis,  or  pyonephrosis.  Suppuration  is  indicated  by 
chills,  irregular  fever,  sweats,  and  leukocytosis. 

During  the  interval  between  the  attacks  there  is  more  or  less  pain 
and  tenderness  over  the  region  of  the  kidneys  and  the  urine  is  stained 
with  blood.  Its  specific  gravity  is  high,  and  albumin  and  long, 
narrow,  hyaline  casts  are  present.  Epithelium  from  the  pelvis  of 
the  kidney,  pus,  and  crystals  indicating  the  character  of  the  calculus 
may  also  be  found. 

Diagnosis. — The  distinctive  features  of  this  affection  are  pain 


NEPHROLITHIASIS  343 

and  tenderness  in  the  back,  persistent  hematuria,  albuminuria, 
scanty  urine  of  high  specific  gravity,  containing  hyaline  casts, 
pus,  and  crystals,  and  the  characteristic  paroxysms  of  renal  colic. 
The  ic-ray  may  be  employed  to  confirm  the  diagnosis. 

In  biliary  colic,  jaundice  is  almost  always  present,  the  stools  are 
grayish  white  in  color,  the  pain  is  nearer  the  median  line  and  radiates 
rather  to  the  upper  abdomen  and  right  shoulder,  and  the  urine  is 
bile-stained. 

In  stone  in  the  bladder,  the  pain  radiates  toward  both  sides,  is  worse 
after  micturition,  and  the  stone  may  be  felt  by  a  sound. 

Prognosis. — The  outlook  is  guardedly  favorable  in  the  absence 
of  complications.  Impaction  may  produce  extensive  disorganiza- 
tion of  the  kidneys,  or  its  passage  along  the  ureter  may  prove  fatal. 
Recurrences  are  common.  The  condition  known  as  gravel  is  the 
least  dangerous.  If  the  stone  is  large  or  there  are  more  than  one, 
the  prognosis  becomes  correspondingly  more  serious. 

Treatment.' — During  the  attack  a  hot  bath  should  be  ordered  and 
a  hypodermic  injection  of  morphine  and  atropine,  or  a  suppository 
of  extract  of  opium,  gr.  j  (0.065  g^-))  ^^^  alcoholic  extract  of  bella- 
donna, gr.  ss  (0.032  gm.),  should  be  administered.  Hot  poultices 
and  hot  fomentations  should  be  applied  to  the  lumbar  region, 
and  diluent  drinks  freely  consumed.  Chloroform  may  be  necessary 
to  relieve  the  pain  in  some  cases.  The  coal-tar  products  are  of  value 
at  times.  During  mild  attacks  of  gravel,  solution  of  potassium 
citrate,  f^ss  (15  c.c),  alone  or  combined  with  camphorated  tincture 
of  opium,  f  5ss  (2  c.c),  is  of  value.  Hematuria  may  be  relieved  by 
alum,  gr.  xx  (1.3  gm.),  or: 

I^.     Fluidextracti  ergotae, 

Tinct.  kramerise aa  f  Bij  aa     60  c.c. 

M.  S. — One  teaspoonful  every  two  hours. 

When  the  calculi  are  large,  numerous,  and  impacted,  or  threaten 
life,  a  surgical  operation  should  be  performed  for  their  removal. 

During  the  interval  efforts  should  be  made  to  prevent  the  forma- 
tion of  the  calculi.  There  are  no  remedies  that  will  dissolve  fully 
formed  calculi,  but  there  are  many  methods  by  which  the  various 
crystals  in  the  blood  and  urine  may  be  kept  in  solution  and  thus 
prevent  the  formation  of  concretions.  If  repeated  examinations  of 
the  urine  show  a  tendency  toward  the  uric  acid  diathesis,  the  alkalies, 
such  as  Buffalo  Lithia  Springs,  Rockbridge  Alum  Springs,  Saratoga, 


344  HYDRONEPHROSIS 

Vichy,  Bedford,  Poland,  and  similar  waters,  potassium  tartraborate 
(cream  of  tartar,  4  parts;  boric  acid,  i  part;  water,  10  parts;  dose,  gr. 
XX  three  times  daily,  diluted) ,  lithium  citrate,  gr.  vtox  (0.3  to  0.6  gm.), 
or  the  following  should  be  administered : 

I^.     Magnesii  carbonat 5j  4  gin- 

Acid,  citrici 5ij  8  gm. 

Sodii  borat 5ij  8  gm. 

Aquse  buUientis Sviii  240  c.c. 

•     M.  S. — Tablespoonful  three  times  daily,  diluted. 

The  diet  in  these  cases  should  consist  largely  of  milk  and  vegetables, 
using  only  a  very  small  quantity  of  meat  and  other  nitrogenous  foods. 

If  there  is  a  tendency  toward  the  deposition  of  phosphates  with 
the  formation  of  calculi,  a  diet  of  meat  and  nitrogenous  substances, 
acidulated  drinks,  distilled  water,  benzoic  acid,  and  boric  acid,  are 
indicated. 

Either  form  of  treatment  will  be  of  equal  value  if  thete  is  any 
tendency  toward  concretion  of  the  oxalates.  Piperazin,  gr.  v 
(0.32  gm.),  three  times  daily,  has  been  employed  with  success  in 
renal  calculi. 

HYDRONEPHROSIS 

Definition. — A  cystic  condition  of  the  kidney,  due  to  distention  of 
the  pelvis  and  calyces  by  urine.  It  may  be  due  to  impaction  of  a 
stone  in  the  ureter,  stenosis  or  congenital  stricture  of  the  ureter,  or 
some  morbid  growth.  The  affection  begins  with  obstruction  of  the 
ureter,  and  is  followed  by  dilatation  of  the  pelvis  of  the  kidney. 
As  the  fluid  accumulates  it  presses  on  the  parenchyma  and  induces 
gradual  wasting  of  that  structure. 

S3anptonis. — When  slight,  there  are  no  distinctive  manifestations, 
but  when  the  amount  of  fluid  is  large,  there  appears  in  the  lumbar 
region  a  soft,  fluctuating,  painless  tumor,  over  which  dullness  may 
be  obtained  by  percussion.  A  clear  fluid,  containing  urea  and  uric 
acid,  will  be  withdrawn  on  aspiration.  The  condition  may  be  inter- 
mittent or  constant,  according  to  whether  the  obstruction  is  or  is 
not  relieved. 

Diagnosis. — The  history,  gradual  onset,  location  of  the  tumor,  the 
relation  of  its  size  to  the  urinary  excretion,  and  the  character  of  the 
aspirated  fluid  will  aid  in  making  a  diagnosis,  but  often  an  explora- 
tory incision  is  necessary*      - 


ACUTE    UREMIA  345 

Prognosis. — The  affection  is  serious,  in  that  if  unrelieved  it  tends 
toward  disintegration  of  the  kidney  substance,  pyonephrosis,  rupture, 
and  ultimately  death. 

Treatment. — The  treatment  is  entirely  surgical  and  includes 
aspiration,  nephrotomy,  and  nephrectomy. 

TUBERCULOSIS  OF  THE  KIDNEY 

Tuberculosis  of  the  kidney  is  seldom  a  primary  affection,  and  is 
usually  a  part  of  a  tuberculous  infection  involving  the  entire  urinary 
tract.  It  is  most  common  in  young  adult  males,  and  its  etiology 
is  that  of  tuberculosis  in  other  regions.  As  elsewhere,  its  lesions 
may  be  miliary  tubercles  or  caseous  nodules.  The  symptoms  re- 
semble pyelitis  from  other  causes,  and  a  distinction  often  can  only 
be  made  by  the  detection  of  tubercle  bacilli  in  the  urine.  (See  page 
325.)  The  affection  is  very  grave,  and  there  is  no  satisfactory  med- 
ical treatment.  A  surgical  operation  offers  the  only  hope  of  relief. 
Untreated  cases  live  from  a  few  months  to  two  or  three  years. 

PERINEPHRITIC  ABSCESS  OR  PARANEPHRITIS 

Inflammation  of  the  capsule  and  the  connective  tissue  surrounding 
the  kidney  terminating  in  suppuration  and  abscess  formation.  It 
may  arise  from  traumatism,  or  it  may  be  due  to  extension  by  per- 
foration of  a  renal  or  other  abdominal  abscess.  It  is  attended  by 
localized  pain,  tenderness,  and  edema;  and  the  patient  flexes  the 
corresponding  thigh  when  sitting  or  lying  to  afford  more  comfort. 
Chill,  fever,  and  sweats  are  present.  The  condition  is  surgical  in 
character,  but  should  always  be  considered  as  a  possibility  in  medical 
renal  affections  attended  by  hectic  symptoms. 

ACUTE  UREMIA 

Synonyms. — Uremic  poisoning;  uremic  intoxication;  uremic  coma; 
uremic  convulsions. 

Definition. — A  group  of  nervous  phenomena,  which  may  develop 
during  the  course  of  acute  or  chronic  Bright's  disease,  and  other 
maladies,  the  result  of  the  retention  or  accumulation  in  the  blood  of 
excrementitious  material,  part  of  which  is  supposed  to  be  urea. 

Causes. — It  is  an  intoxication,  but  the  nature  of  the  toxic  sub- 
stance is  not  known.    Among  the  theories  that  have  been  put  for- 


346  ACUTE   UREMIA 

ward,  and  which  may  be  viewed  as  probable  factors,  are  the  follow- 
ing: (i)  that  uremia  is  due  to  retention  in  the  blood  of  excess  of  urea; 
(2)  that  in  the  blood  urea  is  decomposed  into  carbonate  of  ammonium, 
and  that  it  is  this  latter  which  causes  the  symptoms;  (3)  that  it  is 
not  only  the  retention  of  urea,  but  the  retention  of  urea,  uric  acid, 
alloxur  bases,  and  the  total  excreta;  (4)  that  the  symptoms  are  due 
partly  to  the  salts  of  potassium,  and  partly  to  intermediate  products 
of  proteid  waste;  (5)  that  there  is  some  abnormal  body  present  in 
the  urine,  due  to  disease,  and  possibly  owing  to  the  failure  of  some 
internal  secretion.     No  simple  theory  will  explain  all  cases. 

Symptoms. — Uremic  intoxication  is  the  result  of  the  failure  of 
the  kidneys  to  perform  their  normal  function  of  eliminating  some 
or  all  of  the  poisonous  elements  of  the  urine. 

The  toxemia  may  develop  suddenly,  by  a  convulsive  seizure 
followed  by  coma,  or  slowly  and  gradually.  Usually  the  attack  is 
preceded  by  a  decrease  in  the  urinary  secretion  and  slight  or  marked 
edema  in  various  parts  of  the  body;  although  it  must  be  borne  in' 
mind  that  in  rare  instances,  during,  or  immediately  prior  to,  the 
appearance  of  the  uremic  phenomena,  the  normal  urinary  flow  has 
been  largely  exceeded. 

The  acute  outbreak  may  manifest  itself  in  a  variety  of  ways. 

Gastrointestinal  Variety. — The  patient  suddenly  experiences  attacks 
of  vertigo,  pallor  of  face,  nausea  and  vomiting,  with  fever,  the  tem- 
perature varying  between  100°  and  io3°F.,  pulse  tense  and  rapid, 
respiration  hurried,  and  the  urine  scanty  with  low  specific  gravity; 
unless  symptoms  are  promptly  relieved,  convulsions  or  drowsiness 
may  occur,  followed  by  coma  and  death.  Rarely  an  acute  maniacal 
outbreak  follows  the  gastrointestinal  symptoms. 

Convulsive  Variety. — Without  any  appreciable  prodromes,  epilepti- 
form convulsions  may  occur,  with  or  without  loss  of  consciousness. 
The  convulsions  may  consist  of  a  single  paroxysm,  or  a  succession 
of  fits  may  follow  one  another  at  intervals  of  a  few  minutes  or  several 
hours,  the  patient  being  in  a  condition  of  more  or  less  profound  insen- 
sibility during  the  intervals.  The  fits  closely  simulate  true  epilepsy. 
In  this  variety  the  temperature  is  high,  from  103°  to  io6°F.  or  more, 
the  pulse  rapid,  with  or  without  tension,  the  respirations  quickened. 
Coma  followed  by  death  is  a  very  common  ending  of  this  variety  of 
uremia;  or  after  a  profound  sleep  of  hours  the  patient  gradually 
recovers  his  usual  health.  Alcoholic  excesses  are  responsible  for 
many  of  these  attacks. 


ACUTE   UREMIA  347 

Cerebral  Variety,  or  Uremic  Coma. — Develops  gradually,  with  an 
increasing  drowsiness,  associated  with  headache  and  irritability  of 
temper  (mild  mania).  Nausea,  vomiting,  and  rise  of  temperature, 
often  reaching  105°,  rarely  io7°F.,  with  rapid,  full  pulse  may  be 
present,  or  the  patient  may  fall  suddenly  into  a  condition  of  pro- 
found coma,  the  symptoms  closely  resembling  an  apoplectic  stroke, 
excepting  the  high  temperature.  Temporary  blindness  and  tran- 
sient paralysis  are  not  uncommon.  Uremic  coma  is  always  accom- 
panied with  rise  of  temperature  and  stertor.  "The  stertor  is  pecul- 
iar; it  is  not  the  'snoring'  of  apoplexy,  but  a  sharp,  hissing  sound 
produced  by  the  rush  of  expired  air  against  the  teeth  or  hard  palate" 
(Loomis).  The  respirations  are  accelerated,  the  pulse  rapid  but 
minus  tension.  This  variety  may  suddenly  terminate  fatally  with  a 
convulsion,  or  a  deepening  coma  with  prostration  and  cold,  wet 
skin,  with  edema  of  the  lungs,  or,  rarely,  in  gradual  recovery. 

Diagnosis. — Uremia  resembles  a  number  of  conditions  in  which 
convulsions  and  coma  are  prominent  symptoms.  A  specimen  of 
urine  should  always  be  obtained  and  tested  for  albumin.  The 
quantity  is  scant  and  the  percentage  of  urea  is  decreased.  Other 
signs  of  kidney  disease  are  present.  The  breath  has  a  urinous  odor ; 
the  arterial  tension  is  often  high;  the  second  aortic  sound  is  accen- 
tuated; the  pupils  are  small  and  equal,  and  in  acute  outbreaks  there 
is  a  rise  of  temperature  due  to  irritation  of  the  heat  centers. 

Uremic  coma  may  closely  simulate  coma  from  other  causes.  Cere- 
bral apoplexy  may  be  distinguished  by  its  history,  the  age  at  which  it 
occurs,  generalized  arterial  sclerosis,  the  slow,  noisy,  irregular  respira- 
tion, the  pulse  is  slow  and  full,  the  pupils  are  uninfluenced  by  light, 
conjugate  deviation  of  the  eyes,  the  face  is  flushed,  subnormal  tem- 
perature at  first,  with  a  subsequent  rise  above  normal,  permanent 
one-sided  paralysis,  and  an  absence  of  the  urinary  symptoms  com- 
mon to  uremia. 

Epilepsy  is  attended  by  coma  of  short  duration.  The  attack  is 
preceded  by  a  sharp  cry  and  extreme  pallor  of  the  face,  the  counte- 
nance being  dusky  in  uremia.  The  history,  age  of  the  patient,  and 
the  presence  or  absence  of  urinary  symptoms  should  be  considered 
in  making  the  diagnosis. 

Sunstroke  may  be  recognized  by  the  accompanying  circumstances, 
the  history,  the  extremely  high  temperature,  and  the  absence  of 
albuminuria,  and  other  characteristic  urinary  symptoms  of  uremia. 

Opium  poisoning  is  manifested  by  contraction  of  the  pupils,  slow 


348  ACUTE   UREMIA 

respiration,  slow  full  pulse,  and  the  odor  of  laudanum  at  times. 
An  examination  of  the  urine  will  exclude  uremia. 

Alcoholism  may  be  differentiated  by  its  history,  odor  of  the  breath, 
incomplete  loss  of  consciousness,  and  the  absence  of  urinary  symp- 
toms, dropsy,  etc.  Pressure  applied  over  the  supraorbital  notches 
with  increasing  force  will  serve  to  produce  consciousness  in  alcohoHsm. 

Prognosis. — The  condition  is  very  serious.  The  attack  may  end 
in  recovery,  but  recurrences  are  common  and  the  affection  ultimately 
terminates  in  death. 

Treatment. — During  an  attack,  while  the  patient  is  unconscious, 
elimination  should  be  procured  by  the  administration  of  one  or  two 
drops  of  croton  oil,  diluted  by  glycerin  or  sweet  oil,  or  gr.  3^  (0.0165 
gm.)  of  elaterium  in  solution  by  the  mouth.  The  following  enema 
may  be  used: 

I^.     Magnesii  sulph.  , §ij  60  gm. 

Glycerini §j  30  c.c. 

Aquas  bul §iv  120  c.c. 

M.  S. — As  enema. 

Free  sweating  should  be  encouraged  by  the  use  of  the  hot  pack, 
vapor  bath,  or  hot-air  bath,  together  with  the  hypodermic  injection 
of  pilocarpine  hydrochloride,  gr.  3^  (0.016  gm.),  or  the  rectal  injec- 
tion of  an  infusion  of  jaborandi  leaves  (jaborandi  3j,  water  Siv). 
In  robust  individuals,  venesection,  or  cupping  may  be  performed. 
In  feeble  patients,  during  diaphoresis,  the  tendency  toward  edema 
of  the  lungs  should  be  combated  by  the  hypodermic  injection  of 
atropine  sulphate,  gr.  }/qq  (o.ooi  gm.),  and  strychnine  sulphate,  gr. 
3^2  (0.002  gm.).  The  convulsions  are  relieved  by  inhalations  of 
chloroform,  chloral  by  the  rectum,  morphine  hypodermically,  and 
venesection.  When  the  flow  from  a  vein  is  only  a  few  drops,  it 
may  be  increased  by  the  hypodermic  injection  of  amyl  nitrite,  TTlv 
(0.3  c.c),  with  aromatic  spirit  of  ammonia,  Tllxv  (i  c.c). 

Diuresis  should  be  promoted  by  dry  or  wet  cupping,  poultices 
over  the  loins,  hot  compresses  of  infusion  of  digitalis  over  the  abdo- 
men, pilocarpus  rubbed  over  the  kidneys,  and  the  use  of  normal  salt 
solution  subcutaneously  or  by  the  bowel.  Drugs  such  as  infusion  of 
digitalis,  citrated  caffeine,  sparteine  sulphate,  nitroglycerin,  and 
diuretin  may  be  given  hypodermically,  or  by  the  mouth  if  the  patient 
is  able  to  swallow. 

During  the  intervals  or  the  prodromal  period  these  measures 


MOVABLE   KIDNEY  349 

should  also  be  employed  together  with  other  drugs  by  the  mouth. 
The  diet  should  be  milk  in  large  quantities.  Sodium  benzoate, 
5  j  to  ij  (4  to  8  gm.),  in  twenty-four  hours,  may  be  administered  as  it 
is  believed  to  materially  influence  the  condition. 

When  the  gastrointestinal  variety  is  present  the  patient  should 
be  placed  in  bed  and  the  magnesium  sulphate  enema  and  citrated 
caffeine,  gr.  iii  (0.2  gm.),  every  three  hours,  should  be  administered. 
When  the  secretions  have  started  one  of  the  following  powders  should 
be  given  every  two  hours  for  twenty-four  hours  followed  by  Hunyadi 
Janos  water: 

I^.     Hydrargyri  chlor.  mitis gr-  M  to  ^  0.016  to  0.032  gm. 

Sodii  bicarb gr.  ij  o .  130  gm. 

Pulv.  ipecacuanhae gr-  /^  o.oii  gm. 

M.   Disp.  in  chart.  No.  j. 
S. — Use  as  directed. 

The  following  formulas  will  be  found  of  great  value  in  bringing 
about  diaphoresis: 

I^.     Sparteinse  sulphat gr.  iv  0.265  gm. 

Pilocarpinae  hydrochlor .  . .  .    gr.  j  o .  065  gm. 

Infus.  digital f  gij  60.0      c.c. 

M.  S. — Teaspoonful  every  half  hour  or  hour  until  desired  effect 
is  obtained. 

^.     Digitalinae  cryst gr.  3^4  o.ooi  gm. 

Pilocarpinae  hydrochlor ...  .   gr.  3^^  0.016  gm. 

Sparteinse  sulph gr.  3^  o .  032  gm. 

Aquae  destil lUxv  i .  o      c.c. 

M.  S. — For  hypodermic  use;  to  be  repeated  as  necessary. 

I^.     Pilocarpinae  nitrat gr.  ij  o.  13  gm. 

Petrolat fgj  32.0    gm. 

M.  S. — Apply  locally  over  the  kidneys  twice  daily. 

MOVABLE  KIDNEY 

Synonjrms. — Nephroptosis;   floating   kidney;   wandering   kidney. 

Definition. — A    condition    of    the    kidney,    either    congenital    or 

acquired,  in  which  the  tissues  around  and  about  the  organ  are  so  lax 


SSO  MOVABLE   KIDNEY 

and  the  renal  vessels  so  elongated  as  to  permit  the  kidney  to  be  moved 
in  certain  directions,  causing  a  movable  tumor  in  the  abdomen. 

Causes. — The  kidney  is  normally  held  in  position  by  the  layer  of 
peritoneum  which  is  attached  to  the  anterior  surface  of  its  adipose 
capsule.  In  movable  kidney  the  adipose  tissue,  in  which  the  normal 
kidney  is  imbedded,  disappears.  The  renal  vessels  are  in  many 
cases  abnormally  long.  The  condition  may  be  congenital  or  acquired 
and  occurs  with  greatest  frequency  in  women.  Relaxation  of  the 
abdominal  walls  from  pregnancy  or  other  conditions,  the  wearing 
of  tight  corsets  or  girdles  about  the  waist,  violence,  increased  weight 
of  the  kidney,  pressure  of  adjacent  tumors,  traction  of  hernia,  and 
rapid  emaciation  are  important  etiological  factors. 

Symptoms. — Subjective  symptoms  may  be  absent  entirely.  In 
many  cases,  the  patient  experiences  a  heavy,  dragging  pain  in  the 
abdomen,  aggravated  by  standing  or  walking.  Gastrointestinal 
symptoms,  mental  anxiety,  and  hysterical  manifestations  often 
accompany  the  condition.  Various  reflex  disturbances  may  be 
present,  such  as  palpitation  of  the  heart,  neuralgic  pains,  cardialgia, 
irritability  of  the  bladder,  etc.  Torsion  of  the  ureter  and  renal 
vessels  may  occur  at  any  time  and  is  manifested  by  paroxysms  of 
intense  pain  with  symptoms  of  collapse  {Dietl  's  crises) .  The  kidney 
at  times  swells  without  apparent  cause  and  becomes  sensitive  to  the 
touch.  Its  tendency  to  change  its  position  is  its  characteristic 
feature,  and  the  displaced  organ  may  be  found  anywhere  in  the 
abdomen.     Gastroptosis  or  enteroptosis  may  accompany  it. 

Diagnosis. — Physical  examination  is  necessary  in  all  cases.  The 
detection  of  a  sensitive  and  freely  movable  reniform  tumor  of  fixed 
size  and  the  absence  of  the  kidney  from  its  normal  situation  are  the 
distinctive  features.  The  right  kidney  is  most  often  affected; 
pulsation  of  the  renal  artery  may  occasionally  be  felt. 

Prognosis. — The  affection  is  extremely  chronic,  but  rarely  if 
ever  terminates  fatally  in  the  absence  of  complications. 

Treatment. — Measures  directed  toward  improvement  of  the  gen- 
eral health  are  advised.  In  many  cases  the  symptoms  are  entirely 
relieved  by  lying  on  the  back  or  by  wearing  a  suitable  corset  or 
abdominal  supporter  to  retain  the  kidney  in  its  proper  situation. 
When  the  paroxysms  occur,  rest  in  bed,  hot  applications  over  the 
lumbar  regions,  and  opiates  will  be  necessary.  If  these  recur  fre- 
quently, some  form  of  surgical  treatment  such  as  fixing  the  organ  by 
sutures  {nephropexy),  or  extirpation  will  be  required. 


CYSTITIS  351 

CYSTITIS 

Synonym. — Catarrh  of  the  bladder. 

Definition. — An  infectious  inflammation  of  the  vesical  mucous 
membrane,  acute  or  chronic  in  course,  generally  caused  by  patho- 
genic bacteria,  and  characterized  by  rigors,  moderate  fever,  hypo- 
gastric pain,  frequent  but  scanty  urination,  pus  in  the  urine  (pyuria), 
and  severe  vesical  tenesmus. 

Causes. — Acute  cystitis  may  be  due  to  long-continued  retention 
of  urine,  foreign  bodies  in  the  bladder,  pyelitis,  urethritis,  traumatism, 
or  the  infectious  fevers,  especially  diphtheria.  Among  the  bacteria 
that  may  be  found  are  the  Bacillus  coli  communis,  gonococcus,  Staphy- 
lococcus pyogenes,  and  Bacillus  tuberculosis.  These  are  probably 
the  real  causes,  the  other  conditions  simply  predisposing.  Chronic 
cystitis  may  follow  the  acute  variety  or  may  arise  from  chronic 
Bright's  disease,  gout,  calculi,  or  retention  of  urine  such  as  follows 
enlarged  prostate  and  urethral  stricture. 

Pathological  Anatomy. — Acute  catarrhal  cystitis  begins  with,  hyper- 
emia, of  the  mucous  membrane  which  is  manifested  by  redness, 
swelling,  and  edema.  If  the  congestion  is  intense,  the  smaller  capil- 
laries may  rupture  causing  extravasation  of  blood.  Following  the 
hyperemia,  increased  secretion  of  the  small  glands  at  the  base  of  the 
bladder  and  an  increased  growth  and  consequent  desquamation  of 
the  vesical  epithelium  occur.  If  the  inflammation  is  intense  it  may 
terminate  in  suppuration,  ulceration,  or  in  the  formation  of  a  false 
membrane. 

In  chronic  cystitis  "the  mucous  membrane  is  thick,  blue-gray  in 
color,  and  very  tough.  Muco-pus  and  viscid  mucus  are  formed 
in  large  quantities  upon  its  surface.  The  muscular  wall  of  the  blad- 
der may  sometimes  be  half  an  inch  thick,  and  the  fasciculi  give  a 
ribbed  appearance  to  the  internal  surface,  called  the  columnar 
bladder.'  The  hypertrophy  of  chronic  cystitis  may  be  eccentric  or 
concentric.  In  some  cases  diverticula  are  formed,  in  whose  walls  are 
dilated  and  tortuous  veins.  In  nearly  all  cases  bacteria  are  found 
in  abundance"  (Loomis). 

Symptoms. — Acute  cystitis  is  characterized  by  an  abrupt  onset 
with  rigors,  slight  fever,  loss  of  appetite,  sleeplessness,  and  a  feehng 
of  depression.  Micturition  is  frequent  but  the  urine  is  only  voided 
drop  by  drop  and  its  passage  is  followed  by  distressing  vesical  tenes- 
mus.    Duirpain  ov-er  the  bladder  and  in  the  iliac  regions,  and  bum- 


352  CYSTITIS 

ing  along  the  urethra  are  present.  The  urine  is  cloudy,  of  an  alka- 
line reaction,  and  at  times  fetid.  Microscopic  examination  shows 
epithelium,  pus,  red  blood  corpuscles,  and  various  forms  of  bacteria. 

Chronic  cystitis  is  attended  by  an  insidious  onset  and  is  manifested 
by  dull  pain  and  frequent,  scanty  urination.  If  there  is  ulceration 
pf  the  vesical  mucous  membrane,  severe  localized  pain,  hematuria, 
and  emaciation  will  also  be  present.  In  all  cases  there  are  in  addi- 
tion the  symptoms  of  some  obstructive  condition  such  as  stricture, 
calculus,  or  enlarged  prostate  together  with  debility  and  mental 
depression.  The  urine  is  alkaline  and  contains  large  amounts  of 
muco-pus  or  pus.  On  standing  it  deposits  a  thick,  glairy,  viscid 
sediment  in  which  triple  phosphates  and  large  pus  corpuscles  may 
be  detected  by  the  microscope.  Although  the  quantity  of  urine 
voided  by  the  patient  is  small,  the  use  of  the  catheter  after  micturi- 
tion will  in  most  cases  serve  to  withdraw  several  ounces  of  fetid, 
cloudy,  alkaline  urine. 

Diagnosis. — The  reaction  and  characteristics  of  the  urine,  together 
with  the  history  will  serve  to  distinguish  cystitis  from  pyelitis,  inter- 
stitial nephritis,  and  similar  conditions. 

Prognosis. — The  outlook  in  acute  cystitis  is,  as  a  rule,  favorable, 
but  is  controlled  to  a  great  extent  by  the  character  of  the  cause. 
The  chronic  variety  tends  to  persist  indefinitely  and  is  incurable 
after  hypertrophy  of  the  bladder  has  occurred. 

Treatment. — In  the  acute  variety,  the  patient  should  be  placed  in 
bed,  and  a  liquid  diet,  preferably  milk,  should  be  ordered,  care  being 
taken  to  eliminate  all  highly  seasoned  articles.  Warm  applications 
should  be  made  over  the  bladder  and  occasionally  cupping  or  leeching 
may  be  required.  The  urine  should  be  well  diluted  by  large  draughts 
of  pure  water  or  the  alkaline  mineral  waters  such  as  Farmville  lithia, 
Buffalo  lithia,  Rockbridge  alum,  or  Vichy  waters.  Alkalinity  of  the 
urine  from  any  cause  is  relieved  by  the  administration  of  ammonium 
benzoate,  gr.  xx  (1.3  gm.),  in  water  or  the  solution  of  potassium 
citrate,  5j  (3.7  cc).  For  the  pain  and  tenesmus,  a  suppository  of 
extract  of  opium  and  extract  of  belladonna  may  be  necessary  in 
addition  to  the  hot  applications  and  hot  enemas.  Fluidextract  of 
cannabis  indica,  TTtxv  to  xxx  (i  to  2  cc),  every  three  hours,  often 
relieves  the  tenesmus.  A  free  movement  of  the  bowels  obtained  by 
the  administration  of  a  saline  cathartic  is  always  of  value  in  lessening 
the  inflammation  and  its  attendant  symptoms.  The  following  for- 
mulas are  also  of  decided  value  in  this  condition: 


CYSTITIS  353 

I^,     Acidi  benzoic! 

Sodii  borat aa   5ij  aa  8  gm. 

Infusi  buchu,  vel 

Infusi  uvae  ursi 5vj  i8o  c.c. 

M.  S, — Tablespoonful  every  two  hours,  well  diluted. 

I^.     Tinct,  hyoscyami 5vj  24  c.c. 

Tinct.  opii  camph 5vj  24  c.c. 

Potassii  bromidi 

Sodii  bicarb aa  5ijss  aa  10  gm. 

Liq.  potassii  citrat.  q.  s.  ad  5viij  q.  s.  240  c.c. 

M.  S. — One  teaspoonful  every  two  hours,  well  diluted. 

A  valuable  prescription  is: 

I^.     Fluidextract  pichi fBj-  30  c.c. 

Potassii  nitrat 5  j  4  gm. 

Elix.  simplicis f  5iij  90  c.c. 

M.  S. — One  teaspoonful  every  two  hours,  well  diluted. 

Chronic  cystitis  requires  also  a  mild  unirritating  diet  and  the  free 
use  of  the  alkaline  mineral  waters.  The  bladder  should  be  emptied 
several  times  daily  to  prevent  accumulation  and  consequent  decompo- 
sition of  the  urine,  the  underlying  cause  meanwhile  receiving  appro- 
priate treatment.  Eucalyptol,  gtt.  x  to  xv  (0.6  to  i  c.c),  every  four 
hours  diluted,  fluidextract  of  grindelia,  lUxx  to  f5j  (i-3  to  4  c.c), 
three  times  daily,  or  santal  oil,  gtt.  v  to  x  (0.3  to  0.6  c.c),  in  emulsion 
or  capsule  after  meals,  may  be  administered  internally.  Urotropine, 
gr.  V  to  vijss  (0.3  to  0.5  gm.),  boric  acid,  gr.  v  to  x  (0.32  to  0.65  gm.), 
benzoic  acid,  gr.  V  to  XX  (0.32  to  1.30  gm.),naphthalin,gr.v  (0.13  gm.), 
salol,  gr.  X  (0.65  gm.),  or  resorcin,  gr.  v  (0.32  gm.)  may  also  be 
employed.  Irrigation  of  the  bladder  under  aseptic  precautions  is  a 
very  important  feature  of  the  treatment.  Tepid  water  should  be 
used  at  first,  after  which  medicated  solutions  may  be  employed. 
Not  more  than  from  2  to  4  ounces  of  fluid  should  be  injected  at 
first  until  the  capacity  of  the  bladder  has  been  ascertained.  Daily 
injections  are  usually  sufficient.  Sodium  salicylate,  3j  (4  gi^O?  to 
the  pint  (>^  liter),  boric  acid,  5j  (4  gin.),  to  the  pint  {^i  liter), 
silver  nitrate,  gr.  yi  (0.016  gm.)  to  the  ounce  (30  c.c),  or  the  follow- 
ing are  the  fluids  most  commonly  used  for  this  purpose: 

23 


354  EXAMINATION   OF   THE  BLOOD 

I^.     Sodii  borat Sj  30  gm. 

Glycerini f  5ij  60  c.c. 

Aquae f  5ij  60  c.c. 

M.   S. — Add  one  to  two  tablespoonfuls  to  warm  water  and 
use  as  directed. 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS 

GLANDS 

EXAMINATION  OF  THE  BLOOD 

Normal  blood  consists  of  plasma,  corpuscles,  and  plaques.  The 
corpuscles  are  red  and  white.  The  ordinary  red  blood  cell  is  3^200 
inch  in  diameter  and  varies  in  number  from  4,500,000  to  5,000,000 
to  the  cubic  millimeter.  It  contains  hemoglobin,  the  oxygen  carrier 
of  the  blood.  The  white  blood  cells  measure  K500  ^'n.ch  in  diameter 
and  number  from  7000  to  10,000  to  the  cubic  millimeter.  The 
blood  plaques  number  about  200,000  to  the  cubic  millimeter. 

The  specific  gravity  of  normal  blood  varies  from  1050  to  1060. 
It  may  be  ascertained  by  the  preparation  of  a  number  of  solutions 
of  glycerin  and  water  of  varying  specific  gravities  from  1040  to  1080. 
A  drop  of  blood  is  placed  in  each  solution.  The  solution  in  which 
the  drop  of  blood  remains  stationary  is  of  the  same  specific  gravity 
as  the  blood  under  examination.  Hammerschlag  adds  a  drop  of 
blood  to  a  mixture  of  chloroform  and  benzol  and  then  increases  the 
quantity  of  either  constituent  until  the  drop  of  blood  neither  rises 
nor  falls  but  becomes  stationary.  The  specific  gravity  of  the  mixture 
is  then  taken  by  the  ordinary  means.  Increased  specific  gravity  of 
the  blood  is  observed  in  infancy  and  in  acute  febrile  diseases  such 
as  diphtheria,  pneumonia,  pleurisy,  etc.  Decreased  specific  gravity 
is  common  in  healthy  women,  and  in  anemia,  chlorosis,  and  leukemia. 

The  reaction  of  the  blood  is  normally  alkaline.  The  alkalinity 
is  diminished  in  pernicious  anemia,  simple  aijemia,  leukemia,  uremia, 
diabetes,  jaundice,  chronic  rheumatism,  gout,  carbon  dioxide  and 
phosphorus  poisoning,  febrile  affections,  and  cachectic  conditions. 
It  is  said,  by  some  observers,  to  be  increased  in  chlorosis. 

The  color  of  the  blood  may  vary  considerably.  To  the  unaided 
eye  arterial  blood  appears  bright  red  while  venous  blood  is  darker  in 
color.  Deficient  oxidation  from  any  cause  gives  rise  to  darkening 
of  the  arterial  blood.     The  blood  is  pale  in  chlorosis,  hydremia,  and 


EXAMINATION    OF    THE   BLOOD 


355 


leukemia,  and  is  of  an  abnormally  bright  red  color  in  poisoning  by- 
carbon  monoxide.  It  assumes  a  brownish -red  or  chocolate  color  in 
poisoning  by  hydrocyanic  acid,  nitrobenzol,  aniline,  and  chlorate 
of  potassium. 

Hemoglobin,  the  coloring  matter  of  the  blood,  may  be  approxi- 
mately estimated  by  means  of  Von  Fleischl's,  Dare's,  or  Tallquist's 
hemoglobino meter,  or  by  the  specific  gravity  method.  Von 
Fleischl's  method  requires  a  metal  stand  with  a  stage  perfomted 
by  a  central  circular  opening  beneath  which  is  placed  a  plaster-of- 
Paris  reflector.  A  small  cell  having  a  glass  bottom  and  divided  into 
two  compartments  is  provided  to  fit  into  the  circular  opening.  A 
wedge-shaped  piece  of  glass,  colored  with  Cassius'  gold-purple  which 
increases  in  intensity  as  thethick  portion  is  reached,  is  mounted  in 
a  frame  and  interposed  between  the  reflector  and  the  circular  open- 
ing. A  graduated  scale  is  provided  on  the  frame  which  may  be 
moved  back  and  forth  by  a  rack  and  pinion.  The  wedge  of  the  glass 
is  so  situated  as  to  obstruct  only 
one-half  of  the  area  of  the  circular 
opening.  In  using  the  apparatus 
each  compartment  of  the  cylin- 
drical cell  is  filled  with  distilled 
water  and  the  wedge-shaped  glass 
placed  at  zero  on  the  scale.  A 
drop  of  blood  is  withdrawn  and 
carried  by  means  of  a  special  cap- 
illary tube  to  the  compartment 
opposite  the  unobstructed  open- 
ing. The  glass  is  then  slowly 
moved  along  until  the  colora- 
tion  of  both  compartments  is 
the  same.  The  percentage  may 
then  be  read  from  the  scale.  In  the  average  person,  a  registration 
of  85  to  90  per  cent,  on  this  scale  may  be  considered  normal.  A 
darkened  room,  using  a  candle  for  illumination,  is  necessary  for  the 
best  results  by  this  method.  The  specific  gravity  method  is  more 
easily  performed.  Benzol  and  chloroform  are  mixed  together  form- 
ing a  solution  having  a  specific  gravity  of  about  1059.  A  drop  of 
blood  is  placed  in  the  mixture.  Chloroform  is  added  if  it  sinks,  and 
benzol  if  it  rises  to  the  top,  until  the  drop  of  blood  is  stationary, 
showing  that  it  and  the  liquid  are  of  the  same  density.     The  specific 


Fig.  40. — Von  Fleischl's  hemoglobinometer. 
{From  Greene's  Medical  Diagnosis.) 


356 


EXAMINATION   OP   THE   BLOOD 


gravity  is  then  taken  in  the  usual  way  and  the  percentage  of  hemo- 
globin may  be  calculated  from  the  following  table  by  Hammerschlag : 


Specific  Gravity 
1033— 1035 
1035— 1038 
1038 — 1040 
1040 — 1045 
1045 — 1048 
1048 — 1050 
1050— 1053 
1053— 1055 
1055— 1057 
1057 — 1060 


Hemoglobin 
25 — 30  per  cent. 
30 — 35  per  cent. 
35 — 40  per  cent. 
40 — 45  per  cent= 
45 — 55  per  cent. 
55 — 65  per  cent. 
65 — 70  per  cent. 
70 — 75  per  cent. 
75 — 85  per  cent. 
85 — 95  per  cent. 


Hemoglobin  is  decreased  in  chlorosis  and  all  forms  of  anemia  and 
is  said  to  be  increased  in  pulmonary  stenosis. 

The  number  of  blood  cells  is  best  determined  by  means  of  the 
Thoma-Zeiss  hemocytometer.     This  apparatus  consists  of  a  glass 

slide  with  a  central  cell,  the  depth  of 
which  is  3^0  1^:1^^ •  Microscopic  lines 
divide  the  floor  of  this  cell  into  400 
squares  each  having  a  cubic  capacity 
of  3^000  mm.  The  surface  of  each 
square  is  3^ 00  square  mm.  Double 
lines  are  used  to  mark  off  groups  of 
16  squares.  Two  pipets  are  used  for 
diluting  the  blood,  the  one  graduated 
to  100  is  employed  for  the  red  cells 
while  the  one  with  the  smaller  scale 
is  used  for  the  white  cells.  Each  pipet 
is  blown  into  a  bulb  near  one  extremity 
to  permit  mixing  of  the  blood  with 
the  diluting  fluid.  The  diluting  fluids 
commonly  employed  are  normal  salt 
solution,  a  2}^  per  cent,  of  potassium  bichromate  solution,  and 
Toisson's  fluid  (methyl  violet,  0.025  gm.;  sodium  chloride,  i  gm.; 
sodium  sulphate,  8  gm.;  glycerin,  30  c.c;  distilled  water,  160  c.c). 
A  ^  per  cent,  solution  of  acetic  acid  is  used  in  counting  the  white 
cells.  The  blood  is  diluted  in  the  proportion  of  i  to  100  or  i  to  200 
in  the  enumeration  of  the  red  blood  cells  and  in  the  proportion  of  i 
to  10  or  I  to  20  in  determining  the  number  of  white  blood  cells. 


Pig.  41. — Thoma-Zeiss  hemo- 
cytometer, showing  pipet,  count- 
ing chamber,  and  ruled  field. 
(_From  Greene's  Medical  Diagnosis.) 


EXAMINATION    OF   THE  BLOOD  357 

In  the  practical  application  of  this  apparatus,  the  puncture  is  made 
in  the  skin  and  the  drop  of  blood  sucked  up  to  the  mark  i  c.c.  on  the 
pipet.  The  diluting  fluid  is  then  drawn  into  the  tube  until  the  mark 
loi  is  reached  (for  red  blood  cells).  The  blood  and  diluting  fluid  are 
then  carefully  mixed  and  after  the  first  few  drops  from  the  pipet  have 
been  rejected,  a  drop  of  the  mixture  is  placed  in  the  cell  of  the  slide 
and  covered  by  a  cover-glass.  After  five  or  ten  minutes  the  slide  is 
placed  under  a  microscope  and  the  corpuscles  counted.  In  the  cal- 
culation, the  number  of  corpuscles  counted  in  all  the  squares  should 
be  multiplied  by  4000  and  the  product  by  the  dilution.  This  entire 
product  should  then  be  divided  by  the  number  of  squares  counted,  the 
quotient  being  the  number  of  corpuscles  in  i  cm.  of  blood. 

The  white  blood  cells  appear  in  several  forms,  each  of  which  re- 
quires special  study. 

The  small  lymphocyte  varies  from  5  to  10  microns  in  diameter  being 
nearly  the  same  size  as  the  red  blood  corpuscles.  It  is  surrounded  by 
a  thin,  scarcely  visible  ring  of  protoplasm.  The  nucleus  is  round  and 
large  and  appears  greenish  blue  when  stained  by  the  acid  fuchsin  of 
Ehrlich's  triple  stain.  In  health  these  cells  constitute  from  20  to  30 
per  cent,  of  all  the  colorless  blood  corpuscles. 

The  large  lymphocyte  is  a  large  mononuclear  cell  possessing  the  same 
characteristics  as  the  preceding  with  the  exceptions  that  the  nucleus 
is  round  or  oval  and  stains  less  deeply,  and  the  non -granular  proto- 
plasm is  relatively  larger  in  amount.  The  diameter  of  this  cell  may 
be  as  high  as  13  to  15  microns.  Transitional  forms  between  the  small 
and  the  large  lymphocyte  are  also  encountered.  The  percentage  of 
large  lymphocyte  varies  from  4  to  8. 

The  transitional  forms  resemble  the  foregoing  except  that  their 
nuclei  are  indented,  or  horse-shoe  shaped  and  the  protoplasm  is 
neutrophilic. 

Polynuclear  leukocytes  are  smaller  than  the  large  lymphocytes  and 
occur  in  three  forms.  The  polymorphonuclear  neutrophils  are  matured 
leukocytes  and  constitute  from  62  to  70  per  cent,  of  the  white  blood 
cells.  The  nucleus  is  decidedly  irregular  and  stains  a  greenish  blue  or 
green  with  Ehrlich's  triple  stain.  The  protoplasm  and  nucleus  con- 
tain fine  granules  which  stain  only  with  neutral  stains.  With  Ehr- 
lich's solution  they  appear  violet  or  purple,  while  the  intervening 
matrix  has  a  pinkish  color.  The  eosinophiles  are  smaller  than  the 
neutrophiles,  but  contain  larger  granules  which  have  a  great  affinity 
for  acid  stains  such  as  eosin  and  the  acid  fuchsin  of  Ehrlich's  triple 


358  EXAMINATION   OF   THE   BLOOD 

stain.  Eosin  stains  these  granules  a  brilliant  pink  while  the  acid 
fuchsin  of  Ehrlich's  stain  causes  them  to  assume  a  copper-red  color. 
There  may  be  more  than  one  nucleus  which  may  be  recognized  by  the 
blue  color  in  the  presence  of  either  of  the  already-mentioned  stains. 
Eosinophils  constitute  from  >^  to  4  per  cent,  of  the  white  blood  cells. 

The  hasophiles  or  mast  cells  contain  granules  which  are  unstained 
by  Ehrlich's  solution  but  which  stain  in  basic  solutions  of  the  aniline 
dyes  such  as  methylene-blue.  These  cells  constitute  from  yi  to  K 
per  cent,  of  the  white  blood  cells.  Myelocytes  are  large,  non- 
ameboid,  blood  cells  resembling  the  large  granular  cells  of  the  bone 
marrow.  The  nucleus  is  single  and  stains  pale  with  the  Ehrlich 
stain.     The  protoplasmic  granules  are  usually  neutrophilic. 

The  red  blood  cells  in  certain  abnormal  conditions  undergo  changes 
in  size,  shape,  and  characteristics.  Nucleated  red  blood  corpuscles 
are  occasionally  encountered  and  may  appear  as  normoblasts,  megalo- 
blasts,  and  microblasts.  Normoblasts  are  about  the  size  of  the  ordi- 
nary red  cells  which  they  represent  in  the  immature  state.  With  the 
Ehrlich-Biondi  stain  the  nucleus  assumes  a  very  deep  blue  color. 
Megaloblasts  are  large  and  irregular  cells  possessing  large  nuclei 
which  stain  pale  green  with  the  Ehrlich-Biondi  solution.  Micro- 
blasts  appear  as  very  small  nucleated  red  blood  cells. 

The  color  index  represents  the  amount  of  hemoglobin  in  each  red 
corpuscle;  it  is  found  by  dividing  the  hemoglobin  percentage  by  the 
percentage  of  red  corpuscles  (taking  5,000,000  or  4,500,000  as  100 
per  cent.).     Thus  it  is  high  in  pernicious  anemia,  e.g., 

-r.  T^  '      = —   =    — -^  =    1.3;   and    low  in   chlorosis,   e.g., 

R.B.C.         1,500,000         30%  ^'  >      6  , 

Hb.  40%  40% 


R.B.C.         4,000,000         80% 


=   0.5. 


Hemoconien,  or  Mueller's  blood-dust,  consists  of  small,  round, 
highly  refractive,  colorless  granules  possessing  molecular  movements 
and  resembling  fat  droplets. 

Microscopical  examination  of  the  blood  requires  special  preparation 
and  staining  of  the  specimen  to  obtain  the  best  results.  After  the 
drop  of  blood  is  withdrawn  it  should  be  placed  between  two  perfectly 
clean  cover-glasses,  over  each  of  which  it  then  forms  a  thin  film. 
After  drying,  the  specimen  is  fixed  by  heat  (100°  to  iio°C.)  in  a 
copper-box  or  blood  oven  for  a  half -hour  or  more,  or  by  being  placed 


ABNORMAL    STATES    OF    THE   BLOOD  359 

in  a  mixture  of  equal  parts  of  absolute  alcohol  and  ether  for  about 
fifteen  minutes.  It  may  then  be  conveniently  stained  by  immersion 
for  a  few  minutes  in  a  diluted  i  per  cent,  alcoholic  solution  of  eosin. 
The  excess  of  the  stain  is  removed  by  washing  the  cover-slip  in  water, 
after  which  it  is  counterstained  with  Delafield's  hematoxylin  solution 
for  one  minute.  The  specimen  is  again  washed  in  water,  dried,  and 
mounted. 

Ehrlich's  triple  stain  may  be  employed  instead.  It  is  made  up  as 
follows:  Saturated  aqueous  solution  of  orange  G.,  40  c.c;  saturated 
aqueous  solution  of  acid  fuchsin,  45  c.c;  saturated  aqueous  solution 
of  methyl-green,  55  c.c. ;  these  are  mixed  together  and  to  this  mixture 
added  distilled  water,  50  c.c;  alcohol,  50  c.c;  glycerin,  15  c.c.  The 
entire  mixture  should  be  kept  in  a  cool,  dark  place  for  a  week 
before  being  used.  When  stained  with  this  solution  the  red  cells 
assume  an  orange  tint,  the  nuclei  of  the  white  cells  appear  greenish 
blue,  the  neutrophilic  granules  are  colored  violet,  and  the  eosinophilic 
granules  are  red. 

ABNORMAL  STATES  OF  THE  BLOOD 

Oligoc5rthemia  is  the  term  applied  to  diminution  in  the  number 
of  red  blood  cells  irrespective  of  the  cause. 

Oligochromemia  consists  in  a  deficiency  in  the  hemoglobin.  It  is 
usually  proportionate  to  the  reduction  in  the  red  blood  cells  except 
in  chlorosis,  in  which  the  hemoglobin  equivalent  of  each  cell  is  greatly 
reduced,  and  pernicious  anemia  in  which  it  is  relatively  high. 

Leukocytosis  is  an  increase  in  the  number  of  white  blood  cells 
with  an  excess  of  the  polynuclear  forms.  It  may  be  encountered  as  a 
physiological  process  in  pregnancy  and  parturition,  in  the  new-born, 
during  digestion,  and  after  physical  exertion.  It  is  observed  as  a 
pathological  condition  in  leukemia,  chlorosis,  diseases  of  the  lymphatic 
glands,  inflammatory  conditions  associated  with  exudation,  many  of 
the  infectious  fevers,  in  malignant  disease,  in  gout,  uremia,  and  simi- 
lar affections,  after  hemorrhage,  and  just  before  death.  Drugs  such 
as  pilocarpine,  ergotine,  salicylates,  and  antipyrine,  and  also  tuber- 
culin induce  leukocytosis.  It  is  not  present  in  uncomplicated  cases 
of  influenza,  typhoid  fever,  typhus  fever,  malaria,  measles,  miliary 
tuberculosis,  or  tuberculosis  unassociated  with  cavity-formation  or 
enlargement  of  the  lymphatic  glands. 

Eosinophilia  is  the  term  applied  to  any  increase  in  the  cells  con- 


360  ABNORMAL    STATES    OF   THE  BLOOD 

taining  eosinophilic  granules.  It  is  observed  in  filariasis,  trichinosis, 
ankylostomiasis,  osteomalacia,  asthma,  and  certain  skin  diseases. 

Leukopenia  is  employed  to  designate  a  marked  reduction  in  the 
number  of  white  blood  cells.  It  is  observed  in  pernicious  anemia; 
also  in  conditions  of  malnutrition  and  starvation. 

Poikilocytosis  is  a  condition  characterized  by  irregularities  in  the 
shape  of  the  red  blood  cells.  They  may  be  oval,  pointed,  angular, 
or  reniform.  It  is  seen  in  pernicious  anemia,  chlorosis,  and  leuko- 
cythemia. 

Microcythemia  or  microcytosis  is  the  term  applied  to  the  condition 
in  which  the  red  blood  cells  are  markedly  reduced  in  size.  It  accom- 
panies the  severe  anemias  and  toxemias. 

Macrocythemia  or  macrocytosis  is  the  opposite  condition,  the 
size  of  the  red  blood  cells  being  greater  than  normal.  It  is  asso- 
ciated with  the  severe  forms  of  anemia,  especially  pernicious  anemia. 

Nucleated  red  blood  cells  are  abnormal  constituents  of  the  blood 
and  are  present  in  the  grave  forms  of  anemia.  Their  varieties  and 
characteristics  have  already  been  described. 

Hydremia  is  an  excess  of  the  watery  constituents  of  the  blood, 
with  a  corresponding  decrease  of  the  cellular  elements.  It  is  present 
in  anemia,  in  anasarca,  and  after  the  ingestion  of  fluids  in  large 
quantities. 

Anhydremia  is  a  condition  in  which  the  fluid  portion  of  the  blood  is 
greatly  diminished.  It  occurs  after  excessive  drains  on  the  system 
from  any  cause,  as  in  hemorrhage  and  cholera. 

Melanemia  is  a  rare  condition  characterized  by  the  presence  of 
black,  brown,  or  yellow  granules  in  the  blood.  It  is  observed  in 
malaria,  relapsing  fever,  melanosarcoma,  and  Addison's  disease. 

Lipemia  means  the  presence  of  fat  in  the  blood.  It  may  be  de- 
tected by  the  microscope  as  minute  fat  globules  or  by  its  black 
coloration  when  stained  with  a  i  per  cent,  solution  of  osmic  acid. 
Lipemia  occurs  in  chronic  alcoholism,  chronic  nephritis,  diabetes, 
pulmonary  tuberculosis,  and  after  injuries  to  the  bone  marrow. 

Parasites  are  encountered  in  the  blood  in  certain  diseases.  They 
may  be  animal  or  vegetable  parasites .  The  principal  animal  parasites 
are  filaria  sanguinis  hominis,  plasmodium  of  malaria,  and  distoma 
hematobium.  The  most  important  vegetable  parasites  are  tubercle 
bacillus,  streptococcus,  staphylococcus,  spirillum  of  relapsing  fever, 
anthrax  bacillus,  typhoid  bacillus,  bacillus  of  glanders,  colon  bacillus, 
and  the  tetanus  bacillus. 


J 


Fig.  42. — Chief  varieties  of  cells  encountered  in  health  and  disease  (Wright's  stain). 
1.  Normal  red  cell.  2.  Common  form  of  polymorphonuclear  leukocyte.^  3-  Lesser 
lymphocyte.  4.  Eosinophilic  myelocyte.  S-  Eosinophilic  leukocyte.  6-6.  Neutrophilic 
leukocytes  :  upper  left,  transitional  form,  on  right  neutrophilic  myelocytes.  7-7.  Large 
lymphocytes.  8.  Normoblast.  8.  Normoblast  showing  division  of  nucleus.  9-  Normo- 
blast nucleus,  lo-ii.  Basophilic  leukocytes.  12.  Megaloblast.  {From  Greene  s  Medical 
Diae:nosis.)  ,    .     ,  ,  ,  . 

[As  the  formula  for  Wright's  stain  is  complicated,  it  is  advisable  to  purchase  the 
solution  ready  made  from  a  reliable  drug  house.] 


ANEMIA  361 

ANEMIA 

Definition. — A  diminution  in  the  number  of  red  blood  corpuscles 
or  the  entire  quantity  of  the  blood  with  alterations  in  its  more  im- 
portant constituents  such  as  albumin  and  hemoglobin.  It  may  be 
local  (ischemia)  or  general  (oligemia),  or  it  may  be  primary  or 
secondary. 

Distinction  between  Primary  and  Secondary  Anemias. — In  Primary 
anemia  the  cause  is  either  entirely  unknown  or,  if  known,  seems  in- 
sufficient for  so  severe  a  disease;  Secondary  anemias  are  symptomatic 
of  some  other  disease  or  injury  (generally  due  to  hemorrhages,  poisons, 
or  infectious  diseases). 

Causes. — The  predisposing  causes  are  female  sex,  pregnancy, 
menopause,  heredity,  and  concealed  foci  of  tuberculosis.  The  exciting 
causes  are  deficient  food,  air,  or  sunshine,  excessive  work,  mental 
shock  and  anxiety,  prolonged  and  frequent  nocturnal  emissions, 
excessive  nursing,  imperfect  nutrition,  chronic  intestinal  catarrh, 
prolonged  discharges,  hemorrhage,  Bright's  disease,  parasites, 
malaria,  syphilis,  cancer,  and  various  toxemias. 

Pathological  Anatomy. — The  blood  is  Hghter  in  color,  due  to  the 
reduction  in  the  red  cells  and  hemoglobin.  It  is  thinner  than  normal 
and  coagulates  slowly  and  imperfectly  on  account  of  the  diminution  in 
the  fibrino-plastic  constituent.  After  death  the  tissues  are  thin, 
shrunken,  and  bloodless,  and  if  the  anemia  has  been  of  long  duration 
patches  of  fatty  degeneration  will  be  observed  in  the  various  organs. 

Symptoms. — Pallor  of  the  skin  and  various  mucous  membranes 
is  marked.  Muscular  weakness  and  loss  of  strength  are  present. 
Febrile  paroxysms  are  not  uncommon.  The  appetite  is  impaired 
and  there  is  imperfect  digestion  with  occasional  attacks  of  vomiting. 
Respiration  is  quickened.  There  are  also  irritability  of  temper, 
vertigo,  swooning,  hysteria,  and  epileptoid  attacks.  The  pulse  is 
rapid  and  full,  and  the  heart  is  irritable  with  systolic  basic  murmurs. 
The  cervical  vessels  pulsate  and  there  is  a  hum  over  the  jugular  vein. 
There  may  be  extravasations  of  blood  into  the  mucous  membranes. 
Nocturnal  emissions  in  the  male  and  deficient  menses  in  the  female 
accompany  the  condition.  In  children  marasmus  is  common. 
Edema  of  the  ankles  is  often  present.  In  long -continued  cases, 
symptoms  of  fatty  change  in  the  various  organs  or  gastric  ulcer  may 
appear.  Examination  of  the  blood  reveals  a  reduction  in  the  number 
of  red  cells  with  changes  in  size  and  shape,  nucleated  blood  cells, 


362  CHLOROSIS 

diminution  in  hemoglobin,  and  an  increase  in  the  number  of  white 
cells. 

Prognosis. — In  secondary  anemias,  those  in  which  the  cause 
can  be  ascertained  and  promptly  overcome,  the  outlook  is  favorable 
in  the  absence  of  complications  and  degenerative  changes.  In  the 
primary  anemias,  such  as  chlorosis,  pernicious  anemia,  leukemia, 
Hodgkin's  disease,  and  splenic  anemia,  the  prognosis  is  less  favorable. 
These  forms  will  be  fully  described  later. 

Treatment. — The  cause  should  be  removed  and  rest,  restricted 
exercise,  fresh  air,  sunlight,  and  a  highly  nutritious  diet  should  be 
advised.  The  various  symptoms  should  be  met  with  suitable  remedies 
as  they  arise.  The  tonics  of  most  value  in  this  condition  are  iron, 
arsenic,  quinine,  and  strychnine.  The  carbonate  of  iron,  gr.  ij  to  v 
(0.13  to  0.32  gm.),  is  most  often  employed;  but  Blaud's  pill,  Basham's 
mixture,  tincture  of  the  chloride  of  iron,  or  other  preparations  of 
iron  may  be  used.  Great  care  should  be  exercised  to  prevent  consti- 
pation while  administering  any  of  the  iron  preparations. 

The  following  alterative  tonic,  known  as  Smith's  (Dr.  A.  H.) 
''four  chlorides,"  is  frequently  of  value: 

I^.      Hydrargyri  chloridi  cor- 

rosivi gr.  j  to  ij  o .  065  to  0.13  gm. 

Liq.    arseni    chloridi....  f5j  4-0  c.c. 

Tinct.  ferri  chloridi 

Acidi hydrochlorici  dil.  aa  f5iv  aa  15.0  c.c. 

Syrupi f5iv  i5-0  c.c. 

Aquas q.  s.  ad  f gvj  180.0  c.c. 

M.  S. — One  dessertspoonful  in  a  wineglass  of  water  after  each 
meal. 

Cases  of  anemia  with  weak  stomach  can  take  the  following:  ''iron 
lemonade"  without  discomfort: 


fe 


I^.     Tinct,  ferri  chloridi f5ij  8  c.c. 

Acid  phosphor,  dil f  5ij  8  c.c. 

Syr.  limonis f  §ss  15  c.c. 

Aquae f  §ij  60  c.c. 

M,  S. — One  teaspoonful,  well  diluted,  after  meals, 

CHLOROSIS 

S)monym. — Green  sickness. 

Definition. — A  pronounced  anemia  met  with  chiefly  in  young- girls 


CHLOROSIS  363 

about  the  age  of  puberty,  characterized  by  diminution  in  the  per- 
centage of  hemoglobin. 

Causes. — The  exciting  cause  is  unknown.  Puberty,  female  sex, 
overwork,  impure  air,  improper  food,  lack  of  sunshine,  prolonged 
lactation,  menstrual  disorders,  heredity,  emotional  disturbances, 
change  of  climate,  and  constipation  are  important  predisposing 
factors. 

Pathological  Anatomy. — The  number  of  red  blood  corpuscles  is 
nearly  normal;  but  there  is  marked  decrease  in  the  hemoglobin,  which 
is  sometimes  as  low  as  20  per  cent.  The  body  is  usually  well  nour- 
ished and  the  subcutaneous  fat  well  distributed.  There  is  pallor  of 
the  organs  and  muscles,  but  there  are  no  alterations  in  the  spleen 
lymphatic  glands,  or  bone  marrow.  The  circulatory  apparatus  is 
usually  imperfectly  developed,  the  heart  and  arteries  being  congeni- 
tally  small.     The  genitalia  are  often  immature. 

Symptoms. — Frequently  the  attention  is  first  called  to  the  condi- 
tion at  the  time  of  some  menstrual  disturbance  such  as  amenorrhea  or 
menorrhagia.  Coincidently,  or  shortly  after  such  an  attack,  the 
complexion  changes,  blondes  becoming  pallid,  waxy,  and  puffy  with- 
out edema,  while  brunettes  assume  a  muddy  or  grayish  color  with 
bluish -black  rings  under  the  eyes.  Weakness  and  fatigue  manifest 
themselves  on  the  slightest  exertion.  Shortness  of  breath  is  common. 
The  heart  is  irritable  and  the  pulse  soft  and  full.  The  peripheral 
veins  may  pulsate.  The  patient  experiences  a  change  of  disposition, 
becoming  morose  and  despondent,  hysterical,  or  melancholic.  The 
appetite  is  capricious  and  perverted,  and  digestion  is  impaired. 
Attacks  of  gastralgia  are  frequent  and  gastric  ulcer  or  phthisis  may 
occur  as  complications.  There  is  no  loss  of  flesh;  the  patient  on  the 
contrary  appears  somewhat  stout.  The  hands  and  feet  are  often 
cold.  The  yellowish -green  tinge  of  the  skin  is  characteristic. 
Functional  cardiac  murmurs  may  be  detected  and  a  hum  may  be 
heard  over  the  jugular  vein,  especially  the  right.  Febrile  attacks  are 
not  infrequent.  Headache  and  neuralgia  may  also  be  present. 
Constipation  is  a  common  accompaniment. 

Examination  of  the  blood  shows  a  decrease  in  the  quantity  of 
hemoglobin,  with  the  result  that  the  blood  is  paler  than  normal.  The 
red  corpuscles  are  also  lighter  in  color  and  show  less  tendency  to  form 
rouleaux;  their  character  also  changes,  not  all  being  of  uniform  size, 
some  normal,  others  small  (microcytes),  others  unusually  large 
(macrocytes),  others  irregularly  shaped  (poikilocytes).     The  number 


sH 


CHLOROSIS 


may  be  normal  4,500,000  to  the  cubic  millimeter,  or  it  may  be  occa- 
sionally increased,  but  it  is  sometimes  lessened,  there  being  as  few  as 
3,000,000  or  rarely  2,000,000.  The  white  corpuscles  are  usually 
normal  in  number,  but  in  some  instances  their  number  is  increased 
(leukocytosis).  Rarely  granular  bodies  are  found  in  the  blood,  and 
these  are  generally  regarded  as  the  products  of  the  degeneration  of  the 
white  blood  corpuscles. 

A. 


Fig.  43. — A,  Normal  blood.  B,  Chlorosis.  C,  Pernicious  anemia.  The  plate  shows 
the  sharp  contrast  between  cells  normally  rich  in  hemoglobin  and  the  light  cell  of 
chlorosis  and  also  the  poikilocytosis  and  marked  variation  in  size  noted  in  pernicious 
anemia.  (A  normoblast  and  megaloblast  also  appear.)  Stained  smears.  (Greene's 
Medical  Diagnosis.) 

Complications. — The  principal  complications  are  gastric  ulcer, 
phthisis,  menstrual  disorders,  gastroptosis,  and  venous  thrombosis. 

Diagnosis. — An  examination  of  the  blood  usually  renders  the 
diagnosis  very  easy;  but  if  impracticable  for  any  reason,  the  peculiar 
color  in  young  girls  associated  with  weakness  and  various  functional 
disorders  should  lead  one  to  suspect  the  presence  of  chlorosis  and  treat 
accordingly.  Tuberculosis,  peptic  ulcer,  lead-poisoning,  nephritis, 
etc.,  may  be  distinguished  from  it  by  exclusion. 


PROGRESSIVE   PERNICIOUS    ANEMIA  365 

Prognosis. — This  is  generally  favorable  under  proper  treatment; 
but  some  time  is  necessary  to  effect  a  cure. 

Treatment. — The  unhygienic  surroundings  that  usually  attend 
these  cases  should  receive  attention.  The  quality  of  the  food  should 
be  improved  and  the  patient  should  receive  an  abundance  of  fresh 
air  and  sunshine,  and  regulated  exercise  should  be  advised.  Work 
should  be  interdicted.  Rest  in  bed  is  very  desirable.  Iron  should  be 
administered  in  some  form,  being  careful  to  guard  against  its  consti- 
pating effect  by  the  use  of  some  laxative.  The  tincture  of  the  chlo- 
ride of  iron  is  usually  employed. 

An  iron  pill  that  has  been  successfully  used  is : 

I^.     Massse  ferri  carb gr.  xlviij  3 .  o  gm. 

Potassii  sulph gr.  xxxiv  2  .  o  gm.' 

Potassii  carb gr.  v  3^  o .  33  gm. 

Pulv.  altheae gr.  jss  0.02  gm. 

Pulv.  acacise q.  s.  q.  s. 

Ft.  pil  No.  xvj,  and  inclose  in  gelatin  capsules. 
M.  S. — One  three  times  daily. 

The  following  is  Blaud's  formula: 

I^.     Pulv.  ferri  sulph. 

Potassii  carbonat aa§ss  aa     15  gm. 

Tragacanthae q.  s. 

Ft.  pil  No.  xcvj. 

M.  S. — One  to  3  or  4  pills  three  times  daily. 

The  addition  of  arsenic  is  necessary  in  some  cases.  The  following 
formula  is  valuable  under  such  circumstances: 

I^.     Ferri  arsenatis gr-  K  2  to  J^    o .  005  to  o .  01 1  gm. 

Ext.  nucis  vomicae. .   gr.  >^    to  }i   o. on  to  0.016  gm. 

Ft.  pil  No.  j. 

M.  S. — After  meals. 

The  saline  laxatives  and  the  alkaline  mineral  waters  are  useful 
adjuncts  to  the  treatment.  Dilute  hydrochloric  acid,  manganese, 
and  phosphorus  may  also  be  employed.  The  blood  should  be  exam- 
ined from  time  to  time  in  order  to  note  the  effects  of  treatment. 

PROGRESSIVE  PERNICIOUS  ANEMIA 

Synon3nns. — Idiopathic  anemia;  essential  anemia. 

Definition. — A  progressive,  pernicious  form  of  anemia,  in  which 


366  PROGRESSIVE   PERNICIOUS    ANEMIA 

the  red  cells  are  specially  diminished  in  number,  of  unknown  cause, 
usually  resisting  all  treatment,  and  toward  its  termination  associated 
with  fever. 

Causes. — The  exciting  cause  of  the  disease  is  unknown.  It  prob- 
ably results  from  the  action  of  some  toxin  generated  in  the  digestive 
tract.  Pregnancy,  syphilis,  intense  mental  anxiety  and  worry, 
middle  life,  and  male  sex  seem  to  predispose  toward  this  affection. 
In  some  it  is  considered  a  hemolysis.  Intestinal  parasites  (both- 
riocephalus  latus  and  ankylostomum  duodenale)  are  responsible 
for  some  cases. 

Pathological  Anatomy. — The  blood  is  scanty  and  pale,  with  altera- 
tions in  the  size,  shape,  and  number  of  the  red  blood  cells  and  dimin- 
ished hemoglobin.  It  coagulates  very  slowly  and  imperfectly. 
There  is  no  increase  in  the  white  corpuscles.  The  bone  marrow 
becomes  red,  and  adenoid  in  character,  containing  nucleated  red  blood 
cells,  macroblasts,  neutrophiles,  and  eosinophiles.  There  is  a 
deposition  of  iron  pigment  in  the  liver  cells  and  those  of  the  spleen. 
The  heart,  larger  arteries,  liver,  spleen,  kidneys,  stomach,  and  muscles 
exhibit  circumscribed  or  diffused  fatty  degeneration.  There  is  not 
much  emaciation,  although  pallor  of  the  surface  of  the  body  is 
pronounced.  The  muscles  are  often  unusually  red.  Changes  in 
the  ganglion  cells  of  the  sympathetic,  sclerosis  of  the  posterior 
columns  of  the  cord,  softening  of  the  lumbar  segment,  and  atrophy 
of  the  gastric  mucous  membrane  may  be  encountered  coincidently. 
Hemorrhages  into  the  skin,  mucous  membranes,  and  retina  may 
also  be  observed. 

Symptoms. — The  affection  begins  insidiously  with  increasing 
languor  and  pallor,  the  muscular  weakness  compelling  the  patient 
to  take  to  his  bed.  Cardiac  palpitation,  dyspnea,  attacks  of  syncope, 
edema,  and  swelling  of  the  ankles  follow.  Petechial  hemorrhages 
scattered  irregularly  over  the  body  surface  make  their  appearance 
and  there  is  often  tenderness  over  the  sternum  and  other  superficial 
bones.  The  weakness  progresses  but  emaciation  is  absent.  The 
pulse  is  large,  soft,  and  jerky;  nervous  pulsations  are  observed;  and 
hemic  murmurs  are  often  heard.  There  is  loss  of  appetite,  and 
nausea,  vomiting,  and  diarrhea  may  occur.  Disorders  of  vision 
are  not  uncommon  and  are  due  to  retinal  hemorrhages.  As  the 
disease  progresses,  a  remittent  form  of  fever  develops,  the  tempera- 
ture frequently  rising  to  102°  to  i04°F. 

Blood  Changes. — The  number  of  red  blood  cells  is  decidedly  re- 


LEUKOCYTHEMIA  367 

duced,  sometimes  it  is  as  low  as  500,000  per  cm.  but  the  hemoglobin 
is  not  correspondingly  diminished  although  its  entire  quantity  is 
considerably  less  than  normal.  The  color  index  is,  therefore,  high; 
1.2  or  1.3  being  common.  The  red  cells  show  marked  alterations  in 
size,  shape,  and  characteristics.  They  may  be  large  and  ovoid 
(megalocytes)  or  they  may  be  small,  round,  and  of  a  deep  red  color 
(microcytes).  Some  of  the  red  corpuscles  are  markedly  irregular 
and  to  these  the  term,  "poikilocytes"  is  applied.  Nucleated  red  cells 
(usually  megaloblasts)  are  almost  constantly  present.  The  blood 
plaques  are  scanty  or  absent.  The  leukocytes  are  usually  diminished 
with  a  relative  increase  in  the  small  mononuclear  forms.  Eich- 
horst's  corpuscles  may  be  encountered. 

Diagnosis. — This  can  only  be  made  with  certainty  from  the  blood 
count  and  a  microscopic  examination  of  a  film.  The  high  color  in- 
dex, the  presence  of  megaloblasts,  and  the  leucopenia  are  the  most 
important  points.  A  severe  anemia  with  a  color  index  of  i  or  i-|-  is 
almost  certainly  pernicious  anemia.  From  secondary  anemia  due  to 
septic  infection,  chronic  hemorrhages  or  concealed  malignant  disease 
{e.g.,  gastric  cancer),  it  is  distinguished  by  the  color  index  which  in 
these  diseases  rarely  reaches  0.8,  and  by  the  leukocytosis  which  usu- 
ally accompanies  them. 

From  chlorosis  it  is  at  once  diagnosed  by  the  color  index  which  in 
chlorosis  is  as  characteristically  low  as  it  is  high  in  pernicious  anemia. 

Prognosis. — The  disease  terminates  in  death  usually  within  one  or 
two  years  after  its  recognition.  Remissions  are  common.  Recovery 
may  occur  in  parasitic  forms  of  the  disease  on  removal  of  the  cause. 

Treatment. — The  treatment  is  unsatisfactory.  Rest  in  bed,  fresh 
air,  good  food,  salt  baths,  massage,  and  similar  hygienic  measures 
should  be  prescribed.  Arsenic  is  of  value  as  it  seems  to  check  the 
progress  of  the  affection.  It  should  be  administered  to  the  point  of 
tolerance.  Iron  should  also  be  given  alone  or  combined  with  arsenic. 
Inhalations  of  oxygen  are  recommended  and  bone  marrow  is  some- 
times employed  internally.  When  due  to  intestinal  parasites,  an- 
thelmintics should  be  administered. 

LEUKOCYTHEMIA 

S5nionyin. — Leukemia. 

Definition. — A  condition  in  which  there  is  an  enormous  increase  in 
the  number  of  white  blood  corpuscles,  with  enlargement  of  the  lym- 


368  LEUKOCYTHEMIA 

phatic  glands,  spleen,  and  often  of  the  bone  marrow — viz.:  splenic, 
lymphatic,  or  myelogenic,  and  is  characterized  by  symptoms  of  pro- 
nounced anemia. 

Causes. — The  true  cause  of  the  disease  is  unknown.  It  occurs 
with  greatest  frequency  in  middle-aged  males  and  is  believed  to  be 
influenced  by  heredity,  traumatism,  and  syphilis.  By  some  observers 
it  is  considered  to  be  of  infectious  origin;  but  this  view  lacks  con- 
firmation. 

Pathological  Anatomy. — The  morbid  anatomy  of  leukemia  includes 

alterations  in  the  blood,  the  spleen,  the  lymphatic  glands,  and  the 

.bone  marrow.     According  to  the  predominance  of  the  organic  lesions, 

it  is  termed  splenic,  lymphatic,  or  myelogenic.     Most  cases,  however, 

are  combinations  of  these  varieties. 

The  spleen  is  increased  in  size,  density,  and  firmness,  and  shows 
hyperplasia  of  its  lymphoid  structure.  The  organ  may  be  adherent 
to  neighboring  structures  and  is  often  the  seat  of  lymphoid  tumors. 
The  liver  is  also  enlarged  and  infiltrated  with  leukocytes.  The 
lymphatic  glands  all  over  the  body  enlarge,  but  are  soft  to  the  touch, 
often  fluctuating  and  movable.  The  solitary  glands,  Peyer's  patches, 
the  tonsils,  and  the  lymph -follicles  of  the  tongue,  pharynx,  and  mouth 
may  partake  of  similar  alterations.  The  red  bone  marrow  reverts  to 
the  embryonal  type.  Its  color  becomes  greenish  yellow  and  the  fat 
disappears.  The  microscope  will  reveal  large  numbers  of  nucleated 
red  blood  cells  in  varying  stages  of  development,  polynuclear  and 
mononuclear  leukocytes,  eosinophiles,  and  large  neutrophiles  with 
single  nuclei  (myelocytes).  The  blood  is  paler  than  normal;  its 
specific  gravity  is  reduced  to  1040  or  lower;  the  white  cells  are  in- 
creased in  number  and  size;  and  the  red  corpuscles  are  reduced  in 
number  and  size. 

Symptoms. — The  onset  is  insidious  and  in  the  early  stages  the 
manifestations  are  identical  with  those  of  simple  anemia.  There  is 
also  swelling  of  the  abdomen  and  a  feeling  of  fullness  and  pain  in  the 
region  of  the  spleen  due  to  enlargement  of  that  organ.  In  the  lym- 
phatic variety  there  is  enlargement  of  the  glands  with  pallor  of  the 
body  surface.  In  the  myelogenic  variety,  the  bones,  especially  the  ribs 
and  sternum,  are  tender  on  pressure  and  the  patient  assumes  a  waxy 
appearance.  The  Hver  and  spleen  are  enlarged  and  moderate  fever 
may  be  present.  In  all  varieties,  emaciation,  weakness,  loss  of 
appetite,  feeble  digestion,  diarrhea,  cardiac  palpitation,  dyspnea,  and 
edema  of  the  ankles  and  eyelids  are  observed.     Hemorrhages  into  the 


LEUKOCYTHEMIA  369 

skin  or  from  the  mucous  membranes  may  be  early  symptoms  or  may 
occur  near  the  termination  of  the  disease.  Priapism  is  an  occasional 
manifestation  of  this  disease.  The  urine  is  high-colored,  scanty,  of 
high  specific  gravity  (1020  to  1030),  and  often  slightly  albuminous. 

The  Blood. — The  blood  is  pale  and  watery  and  the  white  blood 
corpuscles  are  enormously  increased  in  number.  The  leukocytes  in 
some  cases  equal  the  red  blood  cells  in  number.  There  is  also  a  re- 
duction in  the  entire  number  of  blood  cells.  The  blood  coagulates 
slowly,  and  its  specific  gravity  and  alkalinity  are  subnormal.  The 
addition  of  a  drop  of  dilute  gentian-violet  solution  stains  the  white 
cells  blue  and  they  may  then  be  readily  detected.  Nucleated  red 
cells  and  poikilocytes  are  present  and  the  hemoglobin  is  diminished. 
Blood  plaques  are  somewhat  increased.  Charcot's  crystals  are  often 
present.  In  splenomyelogenous  leukemia  the  leukocytes  are  enor- 
mously increased,  being  as  many  as  200,000  to  500,000  per  cubic 
millimeter.  The  chief  feature  of  the  blood  is  the  large  number  of 
myelocytes  which  it  contains.  All  varieties  of  leukocytes  are  increased 
in  number,  but  the  overwhelming  number  of  myelocytes  and  poly- 
nuclear  neutrophils  generally  results  in  the  percentage  of  the  others 
being  low.  Lymphatic  leukemia  is  rare  and  may  be  acute  or  chronic 
in  form.  The  acute  form  occurs  usually  in  children  and  is  attended 
by  lymphatic  enlargement,  hemorrhages,  and  the  presence  of  large 
pale  lymphocytes  in  excess  in  the  blood.  The  chronic  form  is  char- 
acterized by  an  increase  of  the  white  blood  cells  (100,000  being  quite 
usual),  but  to  a  less  extent  than  the  splenic  variety  of  the  disease. 
The  small  lymphocytes  are  affected  especially  by  this  increase 
(amounting  frequently  to  90  per  cent,  of  the  whole) ;  the  other  forms 
of  leukocytes  being  relatively  diminished.  Eosinophiles,  myelocytes, 
and  nucleated  red  cells  are  rarely  present. 

Diagnosis. — As  in  other  affections  associated  with  symptoms  of 
anemia,  microscopical  examination  of  the  blood  is  absolutely  neces- 
sary to  determine  the  true  nature  of  the  disease.  The  enormous 
increase  in  the  white  cells  with  changes  in  their  size,  characteristics, 
and  proportion,  and  the  presence  of  new  cellular  elements  in  the  blood 
are  the  distinctive  features.  Leukocytosis  is  attended  primarily  by 
an  increase  of  the  white  cells,  but  this  increase  is  not  so  great  as  in 
leukemia  and  affects  chiefly  the  polymorphonuclear  neutrophiles. 
The  variations  in  the  characteristics  of  the  cells  will  aid  in  distin- 
guishing the  varieties  of  leukemia  one  from  the  other. 

Prognosis. — Acute  leukemia  terminates  fatally  within  two  or  three 
34 


370  PSEUDOLEUKEMIA 

months;  the  other  forms  seldom  last  more  than  two  or  three  years 
and  also  end  in  death. 

Treatment. — This  is  seldom  satisfactory;  the  various  symptoms 
should  be  treated  as  they  arise,  on  general  therapeutic  principles. 
Rest,  nutritious  diet,  fresh  air,  sunshine,  and  cod-liver  oil,  hypophos- 
phites,  iron,  quinine,  strychnine,  arsenic,  ergot,  or  oxygen  should  be 
prescribed.  Recently  the  Roentgen  ray  has  been  employed  in  the 
treatment  of  this  disease;  and  if  carried  out  carefully  and  system- 
atically, this  form  of  treatment  should  be  at  least  as  satisfactory  as 
the  other  and  older  (unsatisfactory)  remedies. 

PSEUDOLEUKEMIA 

Synonyms. — Hodgkin's  disease;  pseudoleukocythemia;  lymphatic 
anemia;  lymphadenoma. 

Definition. — An  affection  characterized  by  hypertrophy  of  the 
lymphatic  glands  in  various  parts  of  the  body,  associated  with 
marked  anemia. 

Cause. — Unknown.  It  has  been  considered  as  an  infection  and 
to  bear  some  relation  to  leukemia.  It  chiefly  affects  young  adults 
and  children,  and  occurs  more  frequently  in  men  than  in  women. 

Pathological  Anatomy. — A  hyperplasia  of  the  lymph  glands  inter- 
fering more  or  less  with  their  functions.  The  enlargement  may  be 
confined  to  one  isolated  gland,  or  a  number  may  be  affected  in  differ- 
ent portions  of  the  body,  or  a  number  in  one  location  may  be  simul- 
taneously affected,  causing  a  tumor  varying  in  size  from  an  egg  to 
an  orange  or  even  larger.  The  spleen  and  liver  are  involved  in  two- 
thirds  of  the  cases.  ''The  marrow  of  the  long  bones  may  be  con- 
verted into  a  rich  lymphoid  tissue"  (Osier) .  The  red  blood  corpuscles 
are  decreased  in  number  and  altered  in  size  and  shape;  the  white 
blood  corpuscles  may  be  slightly  increased  in  number,  but  there  is 
no  approximation  to  anything  like  leukocythemia. 

Symptoms. — These  are  a  slowly  developing  anemia  with  isolated 
or  diffused  enlargement  of  the  lymphatic  glands.  As  the  condition 
develops,  fever  of  a  remittent  character  occurs,  with  feeble  cardiac 
action  and  shortness  of  breath.  Hemorrhages  may  occur.  The 
patient  grows  progressively  worse  with  all  the  associated  symptoms 
of  deficient  blood,  death  occurring  by  asthenia. 

Diagnosis. — A  study  of  the  clinical  history  will  prevent  error, 
as  tuberculous  or  scrofulous  glands  are  accompanied  with  tuber- 


HEMOPHILIA  371 

culous  changes  elsewhere;  and  leukemias  do  not  present  the  same 
blood  picture  as  pseudoleukemia. 

Prognosis. — Unfavorable.  The  progress  may  be  slow,  but  it  is 
none  the  less  toward  a  fat^l  termination.  The  duration  is  from  two 
to  three  years. 

Treatment. — The  treatment  is  that  of  pernicious  anemia.  Surgical 
intervention  is  sometimes  necessary  to  relieve  the  dyspnea.  Radio- 
therapy may  be  of  value  in  some  cases. 

ERYTHREMIA 

Sjmonyms. — Vaquez's  disease;  Osier's  disease. 

Definition. — ^A  rare  disease  characterized  by  an  increase  in  the 
number  of  red  blood  corpuscles,  enlargement  of  the  spleen  and 
cyanosis. 

Etiology. — The  cause  is  unknown;  probably  it  is  due  to  hyper- 
activity of  the  erythroblastic  tissue  of  the  bone  marrow. 

Symptoms. — There  is  an  enormous  increase  in  the  number  of  red 
blood  corpuscles,  as  many  as  10  or  12  millions  to  the  cubic  milli- 
meter being  observed;  the  hemoglobin  is  increased,  and  the  leuko- 
cytes moderately  increased.  The  spleen  is  much  enlarged;  and 
cyanosis,  particularly  of  the  hands  and  face,  is  frequently  observed. 
Other  symptoms  are  headache,  vertigo,  constipation,  albuminuria 
and  hemorrhages. 

Diagnosis. — This  is  made  by  the  presence  of  the  polycythemia, 
enlarged  spleen,  and  cyanosis,  and  the  absence  of  congenital  heart 
disease.' 

Prognosis  is  unfavorable. 

Treatment  is  symptomatic,  and  uncertain;  splenectomy  is  not 
advised. 

HEMOPHILIA 

Sjmonyms. — Hemorrhagic  diathesis;  bleeders  disease. 

Definition. — A  congenital  condition  characterized  by  a  tendency 
to  uncontrollable  hemorrhages,  with  or  without  abrasions. 

Cause. — Heredity  is  the  most  prominent  etiological  factor.  Males 
are  most  often  affected,  but  the  disease  is  transmitted  by  females. 

Symptoms. — The  bleeding  appears  about  the  period  of  the  first 
dentition,  and  consists  of  spontaneous  hemorrhages  from  the  mucous 
membrane   of   the   nose,    mouth,   lungs,   stomach,   intestines,   and 


372  SCORBUTUS 

genitourinary  passages,  or  in  typical  cases  hemorrhages  occur  directly 
from  the  fingers,  toes,  lobes  of  the  ears,  back  of  the  hands  or  arms, 
without  any  apparent  change  in  skin,  and  continue,  in  spite  of  treat- 
ment, for  days  or  weeks.  Traumatic  hemorrhages  occur  if  an  injury 
of  any  kind  is  sustained  about  the  period  of  the  development  of  the 
bleeding.  Epistaxis  is  common.  Attacks  of  arthritis  with  fever 
frequently  occur. 

Prognosis. — The  condition  usually  terminates  fatally  before 
puberty.  Death  rarely  occurs  in  the  first  bleeding.  The  younger 
the  individual  at  the  time  of. the  development  of  the  disease  the 
more  unfavorable  is  the  prognosis.  The  hemorrhagic  tendency 
may  be  outgrown. 

Treatment. — Internally,  the  administration  of  potassium  chlorate, 
tincture  of  the  chloride  of  iron,  and  ergot  are  believed  to  influence 
the  condition  favorably.  Locally,  pressure,  ice,  heat,  gelatin,  tannic 
acid,  gallic  acid,  calcium  chloride,  fibrin  ferment,  adrenalin  chloride, 
etc.,  may  be  employed. 

SCORBUTUS 

Sj^onyms. — Scurvy;  scorbutic  purpura. 

Definition. — A  peculiar  condition  of  malnutrition  or  anemia, 
characterized  by  great  debility,  mental  lethargy,  hemorrhages  of  the 
skin  and  from  the  mucous  membranes,  and  a  swollen  and  spongy 
condition  of  the  gums  which  tend  to  bleed  on  the  slightest  irritation. 

Causes. — A  deficiency  of  fresh  vegetables  in  the  diet,  and  un- 
hygienic surroundings  are  the  most  common  factors  in  its  production. 
Deficiency  of  potassium  salts,  or  of  malates,  citrates  and  tartrates 
has  been  assigned  as  a  cause.  Mental  depression,  home-sickness 
(nostalgia),  and  similar  disturbances  also  seem  to  influence  the  con- 
dition. It  occurs  most  often  in  sailors  of  the  merchant  marine, 
in  prisons,  in  armies,  and  where  large  bodies  of  men  are  collected 
under  unsanitary  conditions.  By  some  observers  the  disease  is  con- 
sidered infectious. 

Pathological  Anatomy. — The  blood  is  dark  and  fluid,  and  its  com- 
position is  deranged  with  diminution  in  the  potassium  salts.  Anemia 
is  present  but  there  is  no  increase  in  the  white  blood  cells.  The  struc- 
ture of  the  blood-vessels  is  altered,  allowing  spontaneous  hemorrhages 
into  the  skin,  muscles,  joints,  and  internal  organs  and  from  the 
mucous  membranes.  There  is  swelling  and  ulceration  of  the  gums 
often  resulting  in  loss  of  the  teeth.     Ulcers  of  the  ileum  and  colon 


SCORBUTUS  373 

may  be  encountered.  The  spleen  is  enlarged  and  soft,  and  the 
viscera  are  affected  with  parenchymatous  changes. 

Symptoms. — The  onset  is  slow,  with  general  weakness,  lassitude, 
indisposition  to  mental  or  physical  exertion,  and  anemia.  The 
skin  is  rough,  dry,  and  of  a  muddy  pallor  and  the  face  is  pale  and 
bloated.  The  gums  soon  become  swollen  and  spongy  and  may  pre- 
sent a  fungoid  appearance.  They  tend  to  bleed  on  the  slightest 
irritation.  The  teeth  loosen  and  may  fall  out.  The  breath  is  ex- 
tremely offensive.  The  lips  are  pale  and  the  eyes  are  sunken  and 
surrounded  by  dark  blue  circles.  There  is  marked  depression  of 
spirits.  Palpitation  of  the  heart  and  dyspnea  follow  slight  exertion. 
Anemia  is  present,  and  the  red  corpuscles  may  be  3,000,000  or  less. 
Petechial  hemorrhages  of  the  skin  and  bleeding  from  the  various 
mucous  surfaces  are  common.  Brawny  induration  of  the  muscles 
is  often  observed.  Edema  of  the  face  and  ankles  is  not  infrequent. 
Pain,  tenderness,  and  swelling  of  the  joints  may  be  present.  Various 
visual  disturbances  may  occur.  Fever  is  absent  except  in  the  late 
stages  and  in  the  presence  of  complications.  Constipation  is  com- 
mon. The  urine  is  high-colored,  of  increased  density,  and  contains 
an  increase  of  phosphates  and  often  blood. 

Infantile  scurvy  (Barlow's  disease)  is  a  cachectic  condition  occurring 
in  young  children  as  the  result  of  improper  feeding,  usually  fol- 
lowing the  long-continued  use  of  proprietary  foods,  condensed 
milk,  etc..  Prostration,  anemia,  and  general  debility  are  marked. 
In  the  beginning  the  child  lies  with  the  legs  drawn  up  and  immo- 
bile, any  attempt  to  move  them  inducing  pain  and  consequent 
crying;  the  legs  are  not  tender  at  this  stage,  but  soon  ill-defined 
swellings  appear  on  the  lower  extremities  and  extreme  tenderness 
is  manifest.  The  limbs  are  now  everted  and  immobile  (pseudo- 
paralysis). Weakness  becomes  profound  and  hemorrhagic  extra- 
vasations may  be  noted.  Epiphyseal  fractures  are  common.  The 
sternum  and  adjacent  cartilages  appear  depressed  and  localized 
thickening  of  the  various  bones  of  the  body  may  be  observed. 
Prolapse  of  one  eyeball,  puffiness  of  the  upper  lid,  and  subcon- 
junctival ecchymoses  are  not  infrequent. 

Complications. — Dysentery,  typhoid  fever,  or  typhus  fever  may 
exist  conicidently. 

Prognosis. — Recovery  is  the  rule,  both  in  adults  and  infants, 
when  the  appropriate  treatment  is  instituted  early  in  the  course 
of  the  disease. 


374  PURPURA 

Treatment. — The  patient  should  be  removed  to  sanitary  quarters 
and  fresh  vegetables  added  to  the  diet.  The  principal  antiscorbutic 
substances  are  raw  cabbage,  cresses,  potatoes,  sauerkraut,  onions, 
lemon-juice,  oranges,  and  various  fruits.  These  should  be  em- 
ployed in  conjunction  with  meats,  milk,  and  farinaceous  foods.  In 
the  infantile  form  the  artificial  feedings  should  be  properly  adjusted 
by  the  attending  physician  and  in  addition  orange-juice  should  be 
administered.  In  all  forms  the  mouth  should  be  thoroughly  cleansed 
with  mild  antiseptic  and  astringent  lotions.  Iron,  quinine,  strychnine, 
and  the  bitter  tonics  may  be  necessary  to  stimulate  the  appetite  and 
combat  the  exhaustion. 

PURPURA. 

Definition. — An  acute  disease,  characterized  by  purpHsh  discolora- 
tions  of  the  skin,  the  result  of  hemorrhages  into  the  upper  layers 
of  the  cutis  beneath  the  epidermis.  When  the  purpuric  spots  are 
tiny,  like  a  pin-point,  they  are  termed  petechia;  when  larger  in  size, 
they  are  termed  ecchymoses. 

Varieties. — Purpura  simplex;  purpura  hcemorrhagica;  purpura 
urticans;  peliosis  rheumatica. 

Causes. — The  etiology  is  obscure.  The  disease  occurs  most 
frequently  in  debilitated  individuals.  In  many  cases  it  is  secondary 
to  some  other  affection,  but  it  also  occurs  as  a  primary  condition. 
By  some  observers  it  is  believed  to  be  of  infectious  origin. 

Symptoms. — Purpura  simplex  is  the  mildest  form  of  the  affection 
and  is  characterized  by  the  sudden  appearance  of  small,  bright  red 
spots — a  cutaneous  hemorrhage — most  commonly  on  the  legs,  coming 
in  crops,  associated  with  slight  lassitude,  mild  febrile  reaction,  and 
aching  pains  in  the  h'mbs.  The  hue  of  the  spots  rapidly  fades  to  a 
purplish  color  and  they  slowly  disappear.     Relapses  are  common. 

Purpura  hcemorrhagica  (morbus  maculosus  Werlhofii)  has,  in  addi- 
tion to  the  eruption  of  purpura  simplex — the  cutaneous  hemorrhage, 
a  flow  of  blood  from  the  free  surface  of  mucous  membranes.  The 
most  common  hemorrhage  is  epistaxis,  slight  or  profuse.  Other 
hemorrhages  are  hematemesis,  melena,  hematuria,  hemoptysis, 
menorrhagia,  and  also  into  the  substance  of  the  mucous  membranes 
of  the  palate,  cheek,  and  gums.  This  variety  is  associated  with 
great  debility  and  depression,  moderate  fever,  and  disorders  of 
digestion.     Marked  anemia  results  from  the  hemorrhages. 

Purpura  urticans  is  a  combination  of  urticaria  and  purpura  simplex. 


STATUS    LYMPHATICUS  375 

It  is  characterized  by  rounded  and  reddish  elevations  of  the  cuticle, 
resembling  wheals,  but  which  are  not  accompanied,  like  the  wheals 
of  urticaria,  by  any  sensation  of  itching  or  tingling.  They  are  usually 
situated  on  the  legs,  thighs,  breast,  and  arms,  and  are  interspersed 
with  petechise.  They  form  gradually  and  subside  within  twenty- 
four  or  thirty-six  hours.  Relapses  are  frequent.  This  variety  is  also 
associated  with  malaise,  moderate  fever,  and  pains  in  the  limbs. 

Peliosis  rheumatica  (Schoenlein's  disease)  is  characterized  by 
multiple  arthritis  and  a  purpuric  eruption;  frequently  the  arthritic 
symptoms  are  associated  with  urticaria  or  with  erythema  exuda- 
tivum.  Edema  is  often  marked,  as  are  also  the  fever,  sore-throat, 
and  general  constitutional  symptoms.  The  eruption  is  sometimes 
vesicular — pemphigoid  purpura. 

Diagnosis. — Purpuric  spots  may  be  distinguished  from  other  lesions 
of  the  skin  by  their  failure  to  entirely  disappear  on  pressure.  The 
concomitant  symptoms  will  serv^e  to  separate  the  several  varieties 
and  to  distinguish  the  disease  from  scur\y  and  hemophilia. 

Prognosis. — The  prognosis  of  purpura  simplex  and  purpura  urticans 
is  favorable,  but  relapses  are  very  frequent.  Purpura  haemorrhagica 
is  always  a  grave  disease,  often  proving  fatal  from  exhaustion,  or, 
more  rarely,  from  cerebral  or  pulmonary  hemorrhage.  Peliosis 
rheumatica  is  often  a  severe  affection,  but  recovery  is  the  rule. 

Treatment. — Rest  in  bed  with  the  administration  of  a  concentrated 
nutritious  diet,  tonics,  and  stimulants  is  necessary  when  there  is 
much  depression.  Mild  cases,  rheumatic  in  origin,  do  w^ell  with  the 
use  of  the  salicylates  and  potassium  iodide.  In  marked  cases,  arsenic, 
dilute  sulphuric  acid,  tincture  of  the  chloride  of  iron,  ergot,  silver 
nitrate,  digitalis,  quinine,  turpentine,  and  similar  remedies  will  be 
required.     The  following  formula  may  be  employed: 

I^.      01.  terebinthinas f  5ij  8  c.c. 

01.  amygdalas  express.    .  .  .   f 5j  30  c.c. 

Tinct.  opii  deodorat f  5ss  2  c.c. 

Mucil.  acaciae f 5j  30  c.c. 

Aq.  lauro-cerasi. .  .  .q.  s.  ad  f  5iij  a-d       90  c.c. 

M.  S. — One  tablespoonful  every  three  hours,  diluted. 

STATUS  LYMPHATICUS 

Synonym. — Lymphatism. 

A  rare  disease  of  the  blood-making  organs  occurring  in  children 


376  SPLENIC   ANEMIA 

and  young  persons,  characterized  by  a  hyperplasia  of  the  lymphoid 
tissues  throughout  the  body,  including  the  lymphatic  glands,  spleen, 
thymus  gland,  and  bone  marrow.  The  cause  is  unknown.  The 
symptoms  are  secondary  to  the  nutritional  disturbances.  There  is 
a  marked  diminution  of  power  of  resistance;  and  sudden  death,  or 
death  from  a  slight  cause  may  occur.  The  affection  resembles 
pseudoleukemia  very  closely. 

SPLENIC  ANEMIA 

Synonym. — Splenic  pseudoleukemia. 

,  An  anemic  condition  in  which  the  spleen  is  greatly  enlarged  and 
indurated,  and  its  lymphatic  structure  is  destroyed  and  replaced 
by  an  overgrowth  of  the  reticulum.  The  red  blood  cells  and  hemo- 
globin are  diminished.  Microc3rtes,  megalocytes,  poikiloc5rtes,  and 
numerous  nucleated  red  blood  corpuscles  are  present.  The  leukocytes 
are  slightly  increased.  When  splenic  anemia  is  associated  with  cir- 
rhosis of  the  liver  and  ascites,  the  condition  is  known  as  BanWs  disease. 
The  disease  lasts  from  six  months  to  three  years  and  terminates  in 
death.  The  treatment  is  unsatisfactory.  Removal  of  the  spleen 
has  been  followed  by  recovery. 

ADDISON'S  DISEASE 

S3nnon3mi. — The  bronzed-skin  disease. 

Definition. — A  well-marked  constitutional  disease,  characterized 
by  extreme  muscular  weakness,  asthenia,  a  tendency  to  nausea  and 
vomiting,  and  an  exaggeration  of  the  normal  pigmentation  of  the  skin. 

Causes. — Obscure.  Tuberculosis  of  the  suprarenal  capsules  is 
generally  the  cause,  but  scrofula  and  syphilis  have  each  been  given 
as  the  cause.     It  is  usually  encountered  in  middle-aged  men. 

Pathological  Anatomy. — This  includes  (i)  tuberculosis  with 
fibrocaseous  and  calcareous  degeneration;  (2)  cystic  degeneration; 
(3)  fatty  degeneration;  (4)  simple  atrophy;  (5)  chronic  interstitial 
inflammation  which  may  lead  to  atrophy;  (6)  malignant  disease,  in- 
cluding carcinoma  and  sarcoma;  (7)  hemorrhagic  extravasations; 
(8)  embolism  (Tyson).  It  is  essentially  a  disease  of  the  suprarenal 
bodies,  generally  tuberculosis;  but  the  abdominal  sympathetic  system 
is  also  often  involved. 

Symptoms. — The  onset  of  the  disease  is  insidious,  with  a  feeling 


EXOPHTHALMIC    GOITRE  377 

of  extreme  langour,  muscular  fatigue,  asthenia,  indigestion,  anorexia, 
dyspnea,  cardiac  palpitation,  vertigo,  melancholia,  and  excessive 
drowsiness.  The  surface  is  first  pale,  then  like  that  of  melanemia, 
changing  to  icteroid,  later  resembling  the  color  of  a  mulatto,  and 
finally  a  lusterless  bronze.  These  changes  also  occur  on  the  mucous 
membrane  of  the  lips,  tongue,  gums,  and  mouth. 

Prognosis. — An  incurable  disease.     Duration,  a  year  or  two. 

Treatment. — Symptomatic.  Iron  and  arsenic  have  both  been 
recommended,  and  the  administration  of  suprarenal  extract,  gr.  iij 
to  V  three  times  daily  has  been  followed  by  temporary  improvement. 

EXOPHTHALMIC  GOITRE 

Synon3rms. — Graves'  disease;  Basedow's  disease;  Parry's  disease. 

Definition. — A  disease,  characterized  by  protrusion  of  the  eyeballs, 
enlargement  of  the  thyroid  gland,  rapid  pulse,  palpitation  of  the 
heart,  and  tremor. 

Causes. — It  is  probably  due  to  some  perversion  of  function  or 
hyperactivity  of  the  thyroid  gland.  Among  the  exciting  causes 
are  anemia,  shock,  fright,  chagrin,  worry,  and  reverses  of  fortune. 
It  is  more  frequent  in  women  than  in  men. 

Pathological  Anatomy. — The  veins  and  arteries  of  the  thyroid 
gland  are  dilated,  the  result  of  a  vasomotor  paralysis.  The  enlarge- 
ment of  the  gland  is  the  result  of  the  dilated  vessels,  and  a  serous 
infiltration  of  its  tissues,  followed,  if  long-continued,  by  hypertrophy. 
The  thyroid  resembles  an  activel}'-  secreting  gland.  A  considerable 
increase  of  fat  behind  the  eyeballs  has  been  observed.  In  the 
majority  of  cases  more  or  less  anemia  exists.  The  thymus  is  often 
persistent  and  enlarged. 

Symptoms, — The  development  of  the  group  of  symptoms  may  occur 
suddenly,  as  the  result  of  some  great  shock  to  the  nervous  system,  but 
in  the  majority  of  instances  they  develop  slowly  and  insidiously,  with 
cardiac  palpitation,  with  paroxysms  of  more  marked  acceleration,  or 
tachycardia,  the  pulse  rate  varying  from  90  to  120,  150,  and  rarely 
as  high  as  200  beats  per  minute,  and  soon  pulsations  of  the  vessels 
of  the  neck  and  thyroid  gland  may  be  felt  and  seen.  The  enlargement 
of  the  thyroid  gland — the  goitre — appears  gradually  after  the  devel- 
opment of  the  circulatory  disturbances,  although  rarely  it  may  be  the 
first  symptom  observed.  The  goitre  is  elastic,  rather  soft,  and  has 
a  thrill  similar  to  an  aneurysm.     The  degree  of  enlargement  varies 


378  EXOPHTHALMIC   GOITRE 

in  different  cases,  but  it  never  attains  a  very  great  size.  Following 
the  development  of  the  goitre  occurs  the  protrusion  of  the  eyeball — 
the  exophthalmos — which  may  be  confined  to  one  eye,  but  usually 
occurs  in  both.  Prominence  of  the  eyeball  may  be  the  first  symptom 
observed,  but  usually  it  does  not  develop  until  after  the  appearance 
of  the  goitre.  The  degree  of  protrusion  varies  from  a  slight  staring 
expression  to  a  point  so  great  that  the  eyelids  cannot  cover  the  eye- 
balls. Associated  with  the  protrusion  of  the  eyeballs  is  incoordination 
in  the  movements  of  the  eyelids  and  the  eyeball,  the  sign  of  Graefe, 
so  that  when  the  eyes  are  quickly  cast  down,  the  eyelids  do  not 
follow  them,  the  sclerotic  being  visible  below  the  upper  lid.  Diminu- 
tion in  the  power  of  convergence  during  accommodation  {Moebius' 
symptom)  and  widening  of  the  palpebral  angle  {Stellwag's  sign) 
may  also  be  present.  Vision  is  unimpaired.  Conjunctivitis  may 
arise,  the  result  of  the  imperfect  protection  of  the  protruding  ball 
by  the  eyelids.  Pulsation  of  the  retinal  arteries  can  be  seen  with 
the  ophthalmoscope. 

Associated  with  the  pathognomonic  symptoms  are  nervousness, 
tremor,  irritability  of  temper,  headache,  insomnia,  vertigo,  fits  of 
despondency,  aphonia,  and  cough  the  result  of  pressure  of  the  goitre, 
disorders  of  digestion,  increase  of  temperature,  low  arterial  pressure, 
anemia  (or  chlorosis),  excessive  sweating,  and  loss  of  flesh. 

Diagnosis. — The  fully  developed  disease  presents  no  difficulties  in 
diagnosis,  but  during  its  incipiency,  before  the  characteristic  symp- 
toms have  appeared,  the  disease  may  be  confounded  with  such  condi- 
tions as  cardiac  disease,  neurasthenia,  lithemia,  malaria,  or  incipient 
phthisis. 

Prognosis. — Recovery  occurs  in  a  fair  number  of  cases,  but,  as  a 
rule,  the  course  is  slow  and  protracted.  The  disorders  of  the  circu- 
lation often  lead  to  dilated  heart,  and  ultimately  death  occurs  from 
this  cause.     Relapses  are  frequent. 

Treatment. — One  of  the  first  injunctions  to  be  placed  on  a  case  of 
exophthalmic  goitre  is  rest,  both  physical  and  mental,  as  well  as 
freedom  from  worry  or  emotional  excitement;  little  progress  will  be 
made  if  this  point  be  neglected.  The  associated  anemia  requires  the 
administration  of  tonics  such  as  iron,  arsenic,  etc.,  and  nutritious, 
easily  digested  food.  To  control  the  circulatory  disturbances  dig- 
italis and  strophanthus  (tincture  of  strophanthus,  TTtv  (0.3  c.c),  from 
three  to  six  times  daily)  are  of  inestimable  value.  Silver  nitrate, 
gr.  %  (0.008  gm.),  after  meals  is  of  value,  alternating  with  strophan- 


MYXEDEMA  379 

thus  or  digitalis.  Bartholow  employs  quinine,  ergotine,  and  bella- 
donna, in  combination,  and  obtains  beneficial  effects.  Extract  of 
thyroid  gland  has  been  used  with  good  effect  in  3  gr.  (0.2  gm.)  doses 
three  times  daily.  The  initial  dose  of  this  drug  should  always  be 
small.  Galvanism  to  the  cervical  sympathetic  and  pneumogastric 
is  always  a  beneficial  adjunct  to  the  medicinal  treatment.  Surgical 
intervention  may  be  considered  in  the  failure  of  other  methods  after 
a  fair  trial.  The  general  nervousness,  restlessness,  and  insomnia  will 
often  call  for  special  treatment,  when  use  may  be  made  of  chloral, 
potassium  bromide,  sulphonal,  or  trional.  It  is  better,  however,  not 
to  use  this  class  of  drugs  in  a  routine  manner,  but  for  the  special 
indications  only. 

MYXEDEMA 

Definition. — A  progressive  disease  characterized  by  an  infiltration 
of  the  connective  tissue  with  a  gelatinous  substance,  general  failure  of 
the  health,  and  mental  failure,  due  to  or  associated  with  atrophy  of 
the  thyroid  gland. 

Cretinism  is  considered  akin  to  myxedema,  save  that  it  is  a  congen- 
ital condition  associated  with  alteration  or  absence  of  the  thyroid 
gland. 

Cachexia  strumipriva,  a  condition  following  the  extirpation  of  the 
thyroid  gland,  especially  in  the  young,  gives  symptoms  resembling 
myxedema. 

Causes. — The  cause  of  the  atrophy  of  the  thyroid  gland  is  unknown. 
It  is  more  frequent  in  women  than  in  men  and  usually  develops  about 
middle  life.  The  disease  is  said  to  have  followed  the  extirpation  of 
the  gland  in  the  adult. 

Morbid  Anatomy. — Atrophy  of  the  thyroid  gland,  sometimes  more 
advanced  in  one  lobe  than  the  other,  is  constant.  "The  pituitary 
body  has  been  found  increased  in  size"  (Wood).  Until  the  func- 
tions of  the  thyroid  gland  are  more  fully  understood,  the  steps  in 
the  changes  resulting  from  its  atrophy  can  not  be  explained. 

Symptoms. — The  disease  develops  slowly,  often  a  number  of  years 
elapsing  before  all  the  characteristic  phenomena  are  present.  The 
face  and  neck,  and  often  other  parts  of  the  body,  have  a  bloated 
appearance.  The  normal  wrinkles  are  obliterated,  the  nose  is  wide 
and  thick,  the  lips  thick  and  everted,  the  mouth  enlarged,  as  is  also 
the  tongue,  giving  a  coarse  and  broadened  or  mask-like  appearance  to 
the  features.     The  skin  is  denser  and  does  not  pit  on  pressure,  but  is 


380  TETANY 

pale  or  chalk-like,  or  yellowish  white,  with  often  a  small  reddish  patch 
on  either  cheek.  The  expression  of  the  countenance  is  immobile  and 
stupid.  The  hands  and  feet  are  enlarged,  the  skin  is  coarse  and  dry. 
The  shape  of  the  hands  is  changed,  presenting  a  "spade-like"  appear- 
ance. The  mental  condition  is  sluggish  and  stupid,  with  loss  of 
memory  and  of  interest  in  the  environments  and  affairs  of  life. 
Occasionally  hallucinations  of  sight  occur.  The  tendency  is  toward 
a  dementia.  Patients  often  complain  of  neuralgic  pains  and  numb- 
ness and  a  sense  of  muscular  weakness.  The  temperature  is  always 
below  the  normal.  Anemia  develops  and  often  a  subacute  nephritis 
or  a  glycosuria  or  phthisis  follows. 

Diagnosis. — Dropsy  or  a  general  edema  has  a  superficial  likeness  to 
myxedema,  but  a  study  of  the  symptoms  should  prevent  error,  as 
pitting  on  pressure  does  not  occur  in  myxedema. 

Prognosis. — Under  treatment  a  great  improvement  can  be 
produced,  but  whether  a  permanent  cure  results  is  not  yet  fully 
determined. 

Treatment. — The  body  surface  should  be  protected  from  cold  by 
warm  clothing.  Warm  bathing  followed  by  inunctions  of  olive  oil 
is  also  beneficial.  Warm  climates  are  best  adapted  for  these  patients. 
The  administration  of  thyroid  extract,  beginning  with  gr.  ss  (0.03 
gm.)  after  meals,  gradually  increasing  the  dose  until  several  grains 
are  taken  daily  or  until  symptoms  of  thyroidism  appear,  is  of  great 
value.  The  remedy  should  be  continued  over  a  long  period  and  with- 
held when  evidences  of  thyroidism  such  as  nervousness,  restlessness, 
insomnia,  dyspnea,  rapid  pulse,  cardiac  palpitation,  gastrointestinal 
disorders,  confusion  of  mind,  or  delirium  become  manifest.  The 
anemia  and  muscular  weakness  are  overcome  by  the  use  of  iron, 
strychnine  and  nuclein. 

TETANY 

Synonyms. — Tetanilla;  intermittent  tetanus. 

Definition. — A  rare  disease,  characterized  by  a  succession  of  tonic, 
usually  bilateral,  painful  muscular  spasms,  particularly  of  the  extremi- 
ties, occurring  at  irregular  intervals,  without  loss  of  consciousness. 

Causes. — Tetany  is  now  supposed  to  be  caused  by  some  derange- 
ment of  the  function  of  the  parathyroid  glands.  Some  cases  were 
formerly  believed  to  be  infectious;  others  were  thought  to  have  been 
produced  refiexly  as  in  those  associated  with  gastric  dilatation, 
removal  of  the  parathyroid  gland,  pregnancy,  etc.     It  is  usually  seen 


TETANY  381 

in  rachitic  children  and  young  neurotic  adults.  Heredity,  emotion, 
hysteria,  and  the  infectious  fevers  are  predisposing  factors.  The 
disease  is  rare  in  America.  The  pathology  is  obscure;  a  recent  work 
seems  to  show  that  there  is  a  lack  of  calcium  in  the  blood,  which  is 
supposed  to  be  due  to  the  parathyroid  insufficiency. 

Symptoms. — Tetany  consists  in  the  occurrence  of  intermittent 
spasms  in  the  muscles  of  the  arms,  hands,  legs,  or  feet,  or,  rarely,  the 
face  and  larynx  (laryngismus  stridulus),  associated  with  pain  or 
"cramp."  The  hands  are  thrown  into  a  position  such  as  they  as- 
sume in  writing,  or  such  as  is  taken  by  the  hand  of  a  midwife;  or  the 
hand  may  be  tightly  closed,  or  one  or  more  fingers  may  be  cramped. 
The  elbows  and  shoulders  may  be  affected  at  times.  In  the  feet  the 
toes  are  drawn  down  and  the  instep  upward,  as  in  equinus.  The 
knees  may  be  cramped  or  the  legs  extended.  Any  of  the  muscles  may 
be  involved.  Trousseau  pointed  out  that  in  those  suffering  from 
tetany,  pressure  upon  the  affected  extremities  at  certain  points  will 
excite  the  spasms  {Trousseau's  sign).  The  duration  of  the  spasms 
varies  from  a  few  moments  to  several  hours,  the  intervals  being 
from  an  hour  to  a  day  or  more.  A  slight  tap  over  a  nerve  trunk, 
such  as  the  facial  nerve,  causes  a  contraction  {Chvostek's  symptom). 
A  certain  periodicity  is  noticed  as  to  the  hour  of  the  day  or  night. 
The  electro-contractility  is  increased,  as  are  also  the  reflexes.  Erb 
first  described  the  peculiar  galvanic  exaltation  found  in  this  disease. 
The  consciousness  is  always  preserved,  although  the  patients  are  very 
nervous. 

Diagnosis. — Tetanus  and  tetany  may  be  confounded,  and  yet 
trismus  is  rare  in  the  latter,  and  always  present  in  the  former. 

Prognosis. — Favorable.  Operative  cases  are  generally  fatal  unless 
treated  by  parathyroids. 

Treatment. — The  administration  of  parathyroids  is  indicated.  If 
the  case  is  due  to  surgical  operation,  parathyroids  should  be  grafted  as 
well  as  administered  internally.  Calcium  lactate  in  doses  of  15  gr., 
four  times  a  day,  has  proved  of  service.  The  secretions  and  excre- 
tions should  receive  attention  and  a  normal  body-tone  should  be  main- 
tained. Potassium  bromide,  gr.  xx  to  xl  (1.3  to  2.6  gm.),  well  diluted, 
three  times  daily,  is  often  of  value.  Urethane  gr.  x  (0.6  gm.),  every 
three  or  four  hours,  is  also  highly  recommended.  Gowers  advises 
digitalis  for  the  painful  cramps  in  the  calves  that  occur  in  the  early 
morning  hours  {nocturnal  tetany).  Gray  has  observed  excellent 
effects  follow  the  application  of  cold  to  the  extremities  and  ice  to  the 


382  ACROMEGALY 

spine.     In  all  cases  when  the  symptoms  are  very  severe  it  may  be 
necessary  to  resort  to  sedatives  such  as  morphine  and  hyoscine. 

ACROMEGALY 

Acromegaly  is  a  disease  characterized  by  marked  enlargement  of 
the  osseous  and  soft  structures  particularly  of  the  face,  hands,  and 
feet.  It  occurs  usually  in  males,  developing  in  most  cases  before  the 
age  of  thirty,  and  is  associated  with  disease  of  the  pituitary  body. 
In  addition  to  the  structural  enlargements,  there  are  headache, 
polyuria,  spinal  curvature,  disorders  of  the  special  senses,  headache, 
and  various  neurotic  symptoms.  The  condition  is  incurable.  The 
course  is  chronic  and  may  extend  over  several  years,  death  ensuing 
from  some  intercurrent  disease. 

Treatment  is  of  little  avail.  Extracts  of  pituitary  body,  thyroid 
gland,  spleen,  or  bone-marrow  may  be  administered;  but  the  physi- 
cian should  expect  very  little  benefit,  and  should  promise  none. 

DISEASES  OF  THE  CIRCULATORY  SYSTEM 

PHYSICAL  DIAGNOSIS 

The  methods  employed  in  making  a  physical  examination  of  the 
heart  are:  I.  Inspection.  II.  Palpatation.  III.  Percussion.  IV. 
Auscultation. 

The  precordium  is  the  region  overlying  the  heart  and  to  which  the 
physical  examination  is  applied.  It  may  be  unduly  prominent  as  the 
result  of  rickets,  cardiac  hypertrophy,  cardiac  dilatation,  pericardial 
effusions,  localized  pleural  effusions,  empyema,  and  aneurysms.  It 
may  be  abnormally  depressed  as  the  result  of  spinal  curvature,  rickets, 
or  the  shrinking  following  remote  pericarditis  and  empyema.  The 
interspaces  bulge  in  pericardial  effusion  and  are  retracted  when 
adhesions  form.  A  change  in  the  color  of  the  integument  of  the  pre- 
cordial region  is  nearly  always  induced  by  a  purulent  pericardial  or 
pleural  effusion  on  the  verge  of  rupture. 

Inspection  serves  to  detect  the  exact  point  of  the  cardiac  impulse, 
and  the  presence  or  absence  of  any  abnormal  pulsations,  or  any 
change  in  the  form  of  the  precordium.  Normally,  the  impulse  is 
visible  only  in  the  fifth  interspace,  midway  between  the  left  nipple 
and  the  left  border  of  the  sternum,  its  area  covering  about  i  square 


PHYSICAL   DIAGNOSIS  383 

inch,  most  distinct  in  the  thin,  while  often  barely  seen  in  the  very 
fleshy;  often  displaced  downward  by  full  inspiration  and  elevated  by 
complete  expiration. 

The  position,  area,  and  force  of  the  impulse  may  be  altered  by 
disease. 

The  position  may  be  moved  to  the  right  by  left-sided  pleural  effu- 
sions, by  chronic  pulmonary  or  pleural  disease  of  the  right  side  associ- 
ated with  retraction,  and  as  the  result  of  transposition  of  the  viscera. 
Displacement  downward  may  be  caused  by  cardiac  hypertrophy, 
pulmonary  emphysema,  mediastinal  growths,  and  aneurysm  of  the 
arch  of  the  aorta.  It  may  be  displaced  upward  by  a  pericardial 
effusion  or  abdominal  tumors.  It  may  be  moved  farther  to  the  lejt 
as  the  result  of  left-sided  cardiac  hypertrophy  or  dilatation,  retrac- 
tion of  the  left  side  following  chronic  lung  or  pleural  disease,  right- 
sided  pleural  effusion,  abdominal  growths,  and  pericardial  effusion. 

The  area  of  the  impulse  is  enlarged  by  pericardial  adhesions, 
cardiac  hypertrophy,  cardiac  dilatation,  and  by  thinning  of  the 
chest  walls  and  shrinking  of  the  lungs  from  any  cause.  The  area 
may  be  diminished  by  pericardial  effusion  and  emphysema. 

The  force  of  the  impulse  may  be  increased  by  excitement,  ex- 
ophthalmic goitre,  certain  drugs,  various  forms  of  reflex  irritation, 
and  cardiac  hypertrophy.  It  is  relatively  increased  by  conditions 
that  increase  its  area.  It  may  be  decreased  by  cardiac  dilatation  or 
degeneration,  collapse,  pericardial  effusion,  and  emphysema. 

Abnormal  pulsations  may  be  detected  at  times  by  inspection  in 
the  epigastrium,  at  the  base  of  the  heart,  in  the  left  axillary  region, 
in  the  carotid  arteries,  and  in  the  jugular  vein. 

Pulsation  in  the  epigastrium  may  be  due  to  aneurysm  of  the  ab- 
dominal aorta,  abdominal  tumors  lying  over  the  aorta,  enlargement 
of  the  right  ventricle,  and  cardiac  excitement  from  any  cause. 

Basic  pulsation  is  usually  produced  by  aneurysm  of  the  arch  of  the 
aorta  or  cardiac  hypertrophy. 

Axillary  pulsation  (left  side)  may  be  caused  by  cardiac  enlargement, 
pulsating  empyema,  retraction  of  the  left  side  of  the  chest,  and 
aneurysm. 

Abnormal  pulsation  of  the  carotid  arteries  may  be  due  to  ex- 
ophthalmic goitre,  anemia,  cardiac  excitement,  neurotic  temperament, 
aortic  regurgitation,  and  disease  of  the  vessel  walls. 

Jugular  pulsation  may  be  induced  by  coughing,  forced  expiration, 
pericardial  adhesions,  and  tricuspid  regurgitation. 

r         • 


384  PHYSICAL  DIAGNOSIS 

Palpation  confirms  the  observations  of  inspection,  and  also  de- 
termines the  force,  frequency,  and  regularity  of  the  cardiac  impulse. 

The  force  of  the  impulse  is  diminished  by  cardiac  dilatation,  fatty 
and  fibroid  degenerations  of  the  heart,  emphysema,  pericardial  effu- 
sion, and  adynamic  diseases.  The  impulse  is  increased  by  cardiac 
hypertrophy,  during  the  first  stage  of  endocarditis,  and  pericarditis, 
functional  cardiac  disturbances,  and  sthenic  inflammations. 

Palpation  also  serves  to  detect  the  shock  induced  by  the  closure 
of  the  valves.  It  is  most  marked  in  persons  having  thin  chest  walls 
and  in  whom  for  any  reason  there  is  heightened  tension  either  in  the 
aorta  or  in  the  pulmonary  artery. 

Thrills  may  be  also  recognized  by  palpation  and  are  produced  by 
vibration  of  the  blood  in  passing  over  a  rough  surface.  A  thrill  is 
created  only  at  the  time  the  blood  is  passing  through  the  orifices  and  is 
usually  felt  at  the  apex.  A  thrill  or  tremor  obtained  by  palpation 
in  this  area  is  usually  indicative  of  mitral  obstruction.  The  apical 
thrill  is  presystolic  in  time.  A  thrill  (systolic  in  time)  at  the  second 
right  costal  cartilage  is  symptomatic  of  aortic  obstruction.  A 
systolic  thrill  at  the  second  left  costal  cartilage  points  to  pulmonary 
obstruction. 

Pericardial  friction  may  be  detected  by  palpation.  It  has  a  to 
and  fro  movement,  synchronous  with  the  heart's  action,  and  bears 
no  relation  to  respiration. 

Position  of  the  patient  often  alters  the  intensity  of  these  abnormal 
phenomena.  The  upright  posture,  or  slightly  leaning  forward  serves 
to  intensify  friction,  fremitus,  and  thrills. 

Percussion  will  determine  the  boundaries  of  the  superficial  and 
deep  cardiac  space,  the  so-called  precordium. 

The  superficial  cardiac  space  is  that  portion  of  the  heart  not  covered 
by  the  lung  at  the  time  of  inspiration  and  extends  from  the  fourth 
to  the  sixth  costal  cartilages  and  from  the  left  border  of  the  sternum 
to  the  apex  beat.  Its  configuration  is  consequently  triangular. 
This  superficial  area  of  dullness  is  increased  by  cardiac  hypertrophy, 
cardiac  dilatation,  and  pericardial  effusion;  it  is  diminished  at  the 
end  of  full  inspiration,  in  emphysema,  when  the. .heart  is  retracted  by 
pericardial  or  pleural  adhesions,  and  when  air  is  present  in  the  peri- 
cardial or  pleural  sac. 

The  deep  cardiac  space  (precordium)  extends  from  the  third  left 
costosternal  junction  to  the  apex  beat;  from  thence  to  the  junction 
of    the   xiphoid    cartilage    with    the    sternum,    the    base    of    the 


PHYSICAL  DIAGNOSIS  385 

triangle  being  formed  by  a  line  }i,  inch  from  and  parallel  with 
the  right  border  of  the  sternum.  This  area  is  increased  by 
hypertrophy  or  dilatation  of  the  heart  and  pericardial  effusions. 
It  is  apparently  increased  by  shrinking  of  the  lungs  as  in  phthisis 
and  in  consolidation  of  the  anterior  border  of  the  investing  lung. 
It  may  be  diminished  in  emphysema  and  by  the  presence  of  air  in  the 
pleural  or  pericardial  sacs. 

Auscultation  indicates  the  character  of  the  normal  cardiac  sounds 
and  the  point  at  which  they  are  heard  with  greatest  intensity,  and 
should  be  thoroughly  understood  if  abnormal  sounds  are  to  be  fully 
appreciated. 

The  ear  or  stethoscope  applied  to  the  precordium  distinguishes  in 
health  two  sounds,  separated  by  a  momentary  silence — the  short 
pause,  and  the  second  sound  followed  by  an  interval  of  silence — 
the  long  pause. 

The  first  sound,  corresponding  to  the  contraction  of  the  heart- 
systole — is  louder,  longer,  and  of  a  lower  pitch  and  a  more  booming 
quality  than  the  second  sound,  and  has  its  point  of  greatest  intensity 
at  the  cardiac  apex  or  a  little  to  the  left.  It  corresponds  closely  in 
time  to  the  pulsations  as  felt  in  the  carotid  or  radial  arteries. 

The  second  sound  is  shorter,  weaker,  and  higher  in  pitch  than  the 
first  sound,  and  has  a  clicking  or  valvular  quality,  having  its  point 
of  greatest  intensity  at  the  second  right  costal  cartilage  and  a  little 
above,  and  corresponds  to  the  closure  of  the  aortic  and  pulmonary 
valves.  The  sound  made  by  the  closure  of  the  tricuspid  valves  is 
best  isolated  at  the  ensiform  cartilage;  the  sound  made  by  the  clos- 
ure of  the  pulmonary  valves,  at  the  third  left  costal  cartilage. 

The  table  on  page  386  giving  the  phenomena  and  time  of  normal 
cardiac  movements,  will  assist  in  recalling  the  physiology  of  the  heart. 

The  extent  of  surface,  over  which  the  cardiac  sounds  are  heard, 
varies  according  to  the  size  of  the  heart  and  the  condition  of  the  ad- 
jacent organs  for  transmitting  sounds. 

The  cardiac  sounds  my  be  altered  in  intensity,  quality,  pitch,  seat, 
and  rhythm,  or  they  may  be  accompanied,  preceded,  or  followed 
by  adventitious  or  new  sounds,  the  so-called  endocardial  or  cardiac 
murmurs. 

The  intensity  is  increased  by  cardiac  hypertrophy,  irritability  of  the 
heart,  or  consolidation  of  adjacent  lung-structure. 

The  intensity  is  diminished  by  cardiac  dilatation  or  degeneration, 
25 


386 


PHYSICAL  DIAGNOSIS 


Action   of   heart 


Time  in  one- 
tenth  of  the 
heart's  beats 


Systole  of  the 
heart,  or  ven- 
tricular sys- 
tole. 


Diastole  of  the 
heart,  or  ven- 
tricular dias- 
tole. 


Ventricles  contracting,  auricles  dilating.  I  First  cardiac! 

Auriculo-ventricular  valves  (mitral  and  sound  (sys-' 
tricuspid)  suddenly  close  and  remain;  tolic)  dull! 
closed  during  the  whole  time  of  the  and  pro-j 
first  sound.  _  longed. 

Semilunar  valves  (aortic  and  pulmon- 
ary) open,  movement  or  locomotion  of 
heart  causing  the  impulse  or  apex  beat. 

Blood  rushes  out  from  the  ventricles  into 
aorta  and  pulmonary  artery,  and 
dilates  these  vessels  and  their  exten- 
sions (arterial  system). 

Blood  flows  slowly  into  the  auricles 
from  the  vena  cava  and  pulmonary 
veins. 

The  pulse  felt  in  different  arteries  from 
one-thirtieth  to  one-eighth  of  a  second 
later  than  impulse. 

Ventricles  dilating  and  receiving  blood  Second  car- 
from  auricles.  Auricles  dilating  and  diac  sound 
receiving  blood  from  veins.       _  (diastole) 

Auriculo- ventricular  valves  (mitral  and  short  and 
tricuspid)  open.  sharp. 

Dilated  pulmonary  artery  and  aorta 
recoil  and  suddenly  close  the  semilunar 
valves  (aortic  and  pulmonic),  which 
remain  closed  during  the  whole  of  the 
second  sound  and  the  interval  of 
silence. 

Ventricles  and  auricles  still  continue  toj  Period  of 
dilate — viz.,  receive  blood.  Near  the:  silence  or 
close  of  this  period  the  auricles,  being  rest, 
fully  dilated  (filled  with  blood),  sud- 
denly contract  and  complete  the  dila- 
tation of  the  ventricles. 


About  four- 
t  en  ths  of 
the  heart's 
beats  or 
twenty-four 
sixtieths  of 
a  second. 


About  three- 
tenths  of 
the  heart's 
beats,  or 
eighteen- 
sixtieths  of 
a  second. 


About  three- 
tenths  of 
the  heart's 
beats,  or 
eighteen- 
sixtieths  of 
a  second. 


pericardial  effusion,  or  eraphysematous  lirng  overlapping  the  heart, 
and  during  the  course  of  adynamic  fevers. 

The  quality  and  pitch  of  the  first  sound  may  be  sharp  or  short  and 
of  higher  pitch  when  the  ventricular  walls  are  thin,  or  have  undergone 
fibroid  change,  the  valves  being  normal;  its  pitch  and  quality  are  also 
raised  during  the  course  of  low  fevers.  The  second  sound  becomes 
duller  and  lower  in  pitch  when  the  elasticity  of  the  aorta  is  diminished 
or  the  aortic  val\res  thickened.  Either  or  both  soiuids  have  a  more 
or  less  metallic  quality  in  irritable  heart  and  during  gaseous  distention 
of  the  stomach. 

The  seat  of  greatest  intensity  of  the  cardiac  sounds  is  changed 
by  displacement  of  the  heart,  pleuritic  effusion,  emphysematous 
lung  overlapping  the  heart,  pericardial  effusion,  and  abdominal 
tympanites. 


PHYSICAL  DIAGNOSIS  387 

The  rhythm  is  often  interrupted  by  a  sudden  pause  or  silence,  the 
heart  missing  a  beat,  or  the  sounds  are  irregular,  confused,  and  tu- 
multuous as  the  result  of  organic  changes  in  the  cardiac  muscle,  valves, 
orifices,  or  vessels.  A  reduplication  of  one  or  both  sounds  of  the  heart 
may  occur. 

The  adventitious  cardiac  sounds  or  murmurs  are  of  two  kinds:  those 
produced  external  to  the  heart,  as  pericardial,  exocardial,  or  frictional 
murmurs,  *  and  those  made  within  the  cardiac  cavity,  endocardial 
murmurs. ' 

Pericardial  murmurs,  or  friction  sounds,  are  made  by  the  rubbing 
upon  one  another  of  the  roughened  surfaces  of  the  pericardial  mem- 
brane during  the  early  stages  of  inflammation.  The  sounds  have  a 
rubbing,  creaking,  or  grating  character,  and  are  differentiated  from 
a  pleural  friction  sound  by  their  being  limited  to  the  precordium, 
synchronous  with  every  sound  of  the  heart,  and  not  influenced  by 
respiration.  They  are  distinguished  from  an  endocardial  murmur* 
by  their  superficial  rubbing,  creaking,  or  grating  character,  and  by 
not  being  transmitted  beyond  the  limits  of  the  heart,  either  along 
the  course  of  the  vessels,  or  to  the  left  axilla  or  back. 

Endocardial  murmurs  are  of  two  kinds,  viz.,  organic  and  functional. 

Functional  endocardial  (also  called  hemic,  or  anemic,  or  blood  mur- 
murs) are  the  result  of  changes  in  the  normal  constituents  of  the 
blood. 

Their  character  is  soft,  they  are  heard  most  distinctly  at  the  base, 
at  the  left  of  the  sternum,  during  the  systole,  are  not  transmitted 
beyond  the  limits  of  the  heart,  either  to  the  left  axilla  or  the  back, 
and  they  are  associated  with  general  anemia. 

Organic  endocardial  murmurs  are  produced  by  blood  currents  pur- 
suing either  a  normal  or  an  abnormal  direction. 

In  health  there  are  two  direct  blood  currents  upon  each  side  of^the 
heart,  viz.,  the  current  from  the  left  auricle  to  the  left  ventricle,  the 
mitral  direct  current;  the  current  from  the  left  ventricle  to  the  aorta, 
the  aortic  direct  current;  the  current  from  the  right  auricle  to  the 
right  ventricle,  the  tricuspid  direct  current;  and  the  current  from  the 
right  ventricle  to  the  pulmonary  artery,  the  pulmonic  direct  current. 

When  from  disease  the  valves  are  not  properly  closed,  the  blood 
is  allowed  to  flow  back  against  the  direct  current,  producing  abnor- 
mal blood  currents;  thus,, when  the  mitral  valve  is  imcompetent,  the 
blood  flows  from  the  left  ventricle  back  into  the  left  auricle  during 
the  cardiac  systole,  producing  the  mitral  regurgitant  or  indirect  cur- 


388  PHYSICAL   DIAGNOSIS 

rent;  when  the  aortic  valves  are  incompetent,  the  blood  is  permitted  to 
flow  from  the  aorta  into  the  left  ventricle  during  the  cardiac  diastole, 
producing  the  aortic  regurgitant  or  indirect  current;  when  the  tricuspid 
valves  are  incompetent,  the  blood  flows  from  the  right  ventricle 
back  into  the  right  auricle  during  the  systole,  producing  the  tricuspid 
regurgitant  or  indirect  current;  when  the  pulmonary  valves  are 
incompetent,  the  blood  flows  from  the  pulmonary  artery  into  the 
right  ventricle,  producing  the  pulmonic  regurgitant  or  indirect 
current. 

The  mitral  direct  current  occurs  during  the  contraction  of  the  left 
auricle,  or  just  before  the  first  sound  of  the  heart  and  immediately 
after  its  second  sound.  The  aortic  direct  current  is  produced  by  the 
contraction  of  the  left  ventricle,  and  occurs  with  the  first  sound  of 
the  heart.  The  tricuspid  direct  current  occurs  during  the  contraction 
of  the  right  auricle,  or  just  before  the  first  or  immediately  after  the 
second  sound.  The  pulmonic  direct  current  is  produced  by  the  con- 
traction of  the  right  ventricle,  occurring  during  the  first  cardiac  sound. 

The  mitral  direct  or  presystolic  murmur  occurs  before  the  first  sound 
of  the  heart  and  immediately  after  the  second  sound.  It  is  caused  by 
a  narrowing  of  the  mitral  orifice,  has  a  blubbering  quality,  well  imi- 
tated by  throwing  the  lips  into  vibration  by  the  breath,  of  a  low 
pitch,  and  it  has  its  seat  of  greatest  intensity  at  the  cardiac  apex,  and 
is  not  transmitted  to  the  left  axilla  or  to  the  base  of  the  heart. 

The  mitral  regurgitant  or  systolic  murmur  occurs  with  the  first 
sound  of  the  heart,  resulting  from  the  failure  of  the  mitral  valves  to 
close  the  mitral  orifice  during  the  systole,  in  consequence  of  which  the 
blood  flows  back,  or  regurgitates  into  the  left  auricle.  It  is  usually 
of  a  blowing  or  churning  character,  and  has  its  seat  of  greatest  inten- 
sity at  the  cardiac  apex,  being  well  transmitted  to  the  left  axilla  and 
inferior  angle  of  the  left  scapula. 

The  aortic  direct  murmur  occurs  with  the  first  sound  of  the  heart. 
It  is  caused  by  a  narrowing  of  the  aortic  orifice,  has  a  rough  or  creak- 
ing character,  is  of  high  pitch,  having  its  seat  of  greatest  intensity  in 
the  second  intercostal  space,  to  the  right  of  the  sternum,  and  is  well 
transmitted  over  the  carotid  artery. 

The  aortic  regurgitant  murmur  occurs  with  the  second  sound  of  the 
heart,  and  is  caused  by  the  failure  of  the  aortic  valves  to  close  the 
aortic  orifice  during  the  diastole,  permitting  the  blood  to  flow  back 
or  regurgitate  into  the  left  ventricle.  It  is  usually  of  a  blowing  or 
churning  character  and  of  low  pitch,  having  its  seat  of  greatest  inten- 


SYMPTOMATOLOGY  389 

sity  over  the  base  of  the  heart,  and  is  well  transmitted  downward 
toward  or  below  the  cardiac  apex.  It  is  the  only  organic  murmur 
heard  in  the  left  side  of  the  heart  which  occurs  with  the  second  sound 
of  the  heart. 

The  tricuspid  direct  murmur  occurs  before  the  first  sound  of  the 
heart  and  immediately  after  the  second  sound.  It  is  caused  by  a 
narrowing  of  the  tricuspid  orifice,  has  a  blubbering  quality,  and  is 
low  in  pitch,  having  its  seat  of  greatest  intensity  near  the  ensiform 
cartilage.     This  murmur  is  exceedingly  rare. 

The  tricuspid  regurgitant  murmur  occurs  with  the  first  sound  of  the 
heart j  the  result  of  the  failure  of  the  tricuspid  valves  to  close  the 
tricuspid  orifice  during  the  systole,  thus  allowing  the  blood  to  flow 
back  or  regurgitate  into  the  right  auricle.  It  is  usually  of  a  blowing 
or  soft,  churning  character,  having  its  seat  of  greatest  intensity  at  the 
ensiform  cartilage.  This  murmur  is  also  very  infrequent,  and  occurs 
mostly  when  the  right  ventricle  is  considerably  dilated,  and  without 
the  existence  of  any  valvular  tricuspid  disease. 

The  pulmonic  direct  murmur  occurs  with  the  first  sound  of  the  heart. 
It  is  generally  connected  with  congenital  lesions.  It  occurs  at  the 
same  instant  that  the  aortic  direct  murmur  occurs,  and  is  distin- 
guished from  the  latter  by  its  not  being  transmitted  into  the  carotid 
artery,  whereas  the  aortic  direct  murmur  is  always  thus  transmitted. 

The  pulmonary  regurgitant  murmur  occurs,  like  the  aortic  regurgi- 
tant murmur,  with  the  second  sound  of  the  heart.  This  murmur  is 
exceedingly  rare,  and  its  presence  is  only  positively  differentiated 
from  the  aortic  regurgitant  murmur  by  the  absence  of  aortic  lesions 
and  symptoms. 

SYMPTOMATOLOGY 

The  Pulse. — The  arterial  pulsation  indicates  the  frequency,  rhythm, 
and  force  of  the  cardiac  action  and  the  blood  pressure. 

Broadbent  gives  the  following  rules,  which  are  worthy  of  record: 
In  feeling  the  pulse,  three  fingers  should  be  placed  on  the  vessel  and 
the  following  points  noted: 

1.  The  frequency,  i.e.,  number  of  beats  per  minute,  the  regularity 
or  irregularity  of  the  beats,  and  their  equality  or  inequality  in  force. 

2.  The  size  of  the  vessel,  whether  large  or  small. 

3 .  The  character  of  the  beat,  whether  abrupt  or  gradual,  long-sus- 
tained or  short,  subsiding  gradually  or  falling  abruptly. 


3  go  SYMPTOMATOLOGY 

4.  The  force  or  strength  of  each  beat. 

5.  The  condition  of  the  vessel  between  the  beats,  whether  full  and 
resistant,  or  readily  compressible. 

6.  The  state  of  the  arterial  wall,  whether  smooth,  regular  and  sub- 
tle, or  irregular,  tortuous  and  rigid. 

In  the  prenatal  period  the  pulse  varies  in  frequency  from  120  to 
140  beats  per  minute;  in  young  children  from  90  to  100;  in  healthy 
adults  from  72  to  80;  and  in  old  age  from  80  to  100.  In  females  it  is 
slightly  greater  in  frequency  than  in  males. 

Tachycardia  or  increased  frequency  in  the  pulse  may  be  physiolog- 
ical or  pathological.  It  may  be  physiologically  accelerated  as  the 
result  of  physical  or  mental  exertion,  fear,  excitement,  etc.,  after  a 
heavy  meai,  or  when  the  erect  posture  is  assumed.  It  may  be  patho- 
logically increased  as  the  result  of  stimulation  by  drugs,  fevers, 
heart  disease,  reflex  irritation,  exophthalmic  goitre,  and  various  mor- 
bid conditions  at  the  base  of  the  brain  interfering  with  the  function  of 
the  pneumogastrics.  It  may  occasionally  arise  as  an  independent 
affection,  no  cause  being  demonstrable. 

Bradycardia  or  infrequency  of  the  pulse,  slow  pulse,  may  be  ob- 
served in  jaundice,  atheroma,  lesions  of  the  cerebral  centers,  especially 
such  as  irritate  the  pneumogastric  nerves  at  their  origin,  fatty 
degeneration  of  the  heart,  aortic  stenosis,  in  the  terminal  stages  of 
certain  febrile  affections,  and  after  the  ingestion  Of  drugs  such  as 
digitalis,  aconite,  and  opium.  Occasionally  this  condition  may  be 
observed  in  health  without  obvious  cause  and  asa  purely  physiolog- 
ical phenomenon.     See  Heart-block,  page  432. 

The  rhythm  of  the  pulse  is  also  subject  to  variations  {arrhythmia). 

The  intermittenf pulse  may  be  observed  as  the  result  of  excessive 
eating,  the  habitual  use  of  tobacco,  coffee,  and  tea,  exercise,  mental 
excitement,  myocardial  disease,  and  reflex  irritation  such  as  produced 
by  constipation,  dyspepsia,  lithemia,  hypochondriasis,  etc. 

The  irregular  pulse  may  be  due  to  the  same  causes  as  the  preceding. 
As  a  pathological  condition,  it  is  most  often  encountered  in  organic 
cardiac  disease,  especially  that  which  gives  rise  to  mitral 
regurgitation. 

The  dicrotic  pulse  is  one  in  which  the  first  impulse  is  quickly  fol- 
lowed by  another  impulse  or  secondary  wave.  It  owes  its  production 
largely  to  conditions  which  relax  the  arterial  walls  and  lower  the 
tension,  especially  adynamic  affections  such  as  typhoid  fever. 

Pulsus  paradoxus  is  that  condition  of  the  pulse  in  which  the  pulse- 


SYMPTOMATOLOGY  39 1 

wave  becomes  small  and  feeble  during  inspiration;  it  may  occur  in 
health  but  is  rather  common  as  the  result  of  pericardial  adhesions. 

Water-hammer  or  Corrigan's  pulse  is  that  pulse  which  is  character- 
ized by  a  short,  sharp,  strong  impulse  which  seems  to  collapse  under 
the  examiner's  fingers.  It  is  best  detected  by  holding  the  arm  up,  and 
is  diagnostic  of  aortic  regurgitation  during  compensation. 

A  full  pulse  is  one  in  which  the  volume  is  large  and  is  encountered 
in  the  robust  and  plethoric;  a  small  pulse  has  a  weak  beat  and  small 
volunie,  and  is  observed  in  exhausting  or  debilitating  conditions, 
aortic  stenosis,  mitral  stenosis,  myocarditis.  Bright 's  disease,  acute 
peritonitis,  and  during  a  chill. 

A  strong  pulse  has  a  strong  impulse  and  very  little  compressibility, 
and  is  found  in  robust  individuals  and  in  cardiac  hypertrophy,  a  weak 
pulse  is  the  direct  opposite  and  attends  asthenic  affections. 

Tension  of  the  pulse  expresses  the  degree  of  distention  of  the 
arteries,  or  blood  pressure.  The  pulse  may  be  hard  or  soft.  A  hard 
pulse  is  one  of  high  tension  or  in  which  the  contractile  power  of  the 
arterial  walls  is  great.  The  artery  consequently  remains  continuously 
full  between  the  beats.  Among  its  causes  may  be  mentioned  plethora, 
increased  cardiac  action  with  contraction  of  the  arterioles,  capillary 
obstruction  from  various  causes,  cardiac  hypertrophy,  arteriosclerosis, 
interstitial  nephritis,  gout,  lithemia,  uremia,  lead-poisoning,  preg- 
nancy, anemia,  apoplexy,  brain  tumor,  etc.  A  soft  pulse  is  one  of 
low  tension  and  easily  compressible,  due  directly  to  a  lowered'tone  of 
the  vessel  walls.  This  may  occur  physiologically.  As  an  abnormal 
condition  it  is  encountered  in  asthenic  affections  such  as  typhoid 
fever,  cardiac  degeneration,  collapse,  etc.  It  may  occur  in  obese 
individuals  and  after  diarrhea,  warm  baths,  hot  applications,  hot 
drinks,  and  copious  urination. 

Palpitation  of  the  heart  consists  of  abnormal  rapidity  with  flut- 
tering and  tremor  of  the  organ,  of  which  the  patient  is  conscious. 
It  is  usually  purely  functional  in  origin  and  may  be  traced  in  most 
cases  to  gastrointestinal  disturbances,  excitement,  hysteria,  overwork, 
etc.  It  may  be  also  due  to  organic  heart  disease,  exophthalmic 
goitre,  and  anemia. 

Blood  Pressure. — This  is  determined  by  means  of  the  sphygmo- 
manometer. The  average  systolic  pressure,  in  health,  is  about  120  to 
135  mm.  for  adults,  and  about  90  to  100  mm.  for  children. 

In  estimating  the  blood  pressure,  it  is  the  usual  practice  to  deter- 
mine the  systolic  pressure,  the  diastolic  pressure,  and  xhe  pulse  pressure. 


392  SYMPTOMATOLOGY 

The  systolic  pressure  is  the  maximum  pressure  occurring  within  the 
vessel  under  observation,  and  is  determined  by  noting  the  figure  on 
the  scale  at  the  moment  when  the  pressure  in  the  sphygmoman- 
ometer is  just  sufficient  to  permit  the  pulse  to  pass  the  constricting 
cuff. 

The  diastolic  pressure  may  be  determined  in  several  ways,  and  is 
about  20  to  30  mm.  less  than  the  systolic  pressure.  This  difference 
between  the  systolic  and  diastolic  pressures  is  called  the  pulse 
pressure. 

Abnormally  high  pressure  {hypertension)  may  occur  in  arterio- 
sclerosis, chronic  interstitial  nephritis,  angina  pectoris,  cerebral 
hemorrhage,  gout,  uremia,  lead-poisoning. 

Abnormally  low  pressure  {hypotension)  may  occur  in  infectious 
fevers,  anemia,  cachectic  conditions,  diabetes  mellitus,  shock  and 
collapse. 

Dropsy. — Serous  infiltration  of  the  cellular  tissues  and  cavities 
of  the  body  frequently  is  indicative  of  heart  disease,  especially  when 
it  is  bilateral.  When  localized  to  certain  regions  as  the  ankles  it  is 
termed  edema,  and  when  generalized  it  is  known  as  anasarca. 

Cyanosis  is  the  term  applied  to  blueness  of  the  body  surface  and 
Is  due  to  deficient  oxidation  of  the  blood  as  the  result  of  local  or  gen- 
eral circulatory  disturbances.  It  therefore  accompanies  \rarious 
forms  of  chronic  heart  disease.  It  may  be  congenital  as  the  result 
of  cardiac  malformations. 

Pain  in  the  precordial  region  may  be  due  to  disease  of  the  heart  or 
pericardium,  neuralgia,  pleurodynia,  myalgia,  localized  pleurisy, 
periostitis,  or  abscess.  Cardiac  disease  may  induce  acute,  excruciat- 
ing pain  in  the  epigastrium.  Disturbances  of  rhythm,  valvular 
disease,  and  angina  pectoris  are  common  causes  of  cardiac  pain. 
Pericarditis  is  attended  by  paroxysmal  pain  over  the  heart  which  may 
radiate  to  the  left  shoulder  and  down  the  arm,  being  increased  by 
pressure,  movement,  and  respiration.  Inflammation,  atheroma,  or 
aneurysm  of  the  aorta  may  be  the  cause  of  pain  in  the  precordial 
region. 

Dyspnea  is  also  a  symptom  of  heart  disease  and  may  be  due  to 
exertion,  or  it  may  occur  paroxysmally.  Orthopnea  is  observed  in 
grave  cases,  as  is  also  rhythmic  dyspnea  or  Cheyne-Stokes  breathing. 

Cerebral  sjnnptoms  may  be  induced  by  cardiac  disease.  Among 
these  may  be  mentioned  vertigo,  faintness,  dullness,  languor,  stupor, 
moderate  delirium,  coma,  chorea,  epileptiform  convulsions,  etc. 


ACUTE   PERICARDITIS  393 

Gastrointestinal  symptoms  such  as  dyspepsia,  flatulence,  nausea, 
vomiting,  and  similar  manifestations  of  gastric  congestion  may  attend 
organic  heart  disease. 

DISEASES  OF  THE  PERICARDIUM 

ACUTE  PERICARDITIS 

Definition. — An  acute  fibrinous  inflammation  of  the  pericardium; 
characterized  by  sHght  fever,  pain,  precordial  distress,  and  disturbed 
cardiac  action  and  circulation.  If  the  inflammation  be  limited  to 
the  parietal  or  visceral  layer,  or  to  a  part  of  either,  it  is  termed  partial 
or  circumscribed  pericarditis;  if  it  involve  the  whole  of  both  surfaces, 
it  is  termed  general  or  difused  pericarditis.  The  inflammation  may 
be  primary  or  secondary. 

Causes. — Primary  pericarditis  resulting  directly  from  cold  and 
exposure  or  injuries  is  rare.  Secondary  pericarditis  follows,  or  is 
associated  with,  rheumatism,  influenza,  scarlatina,  variola,  puerperal 
fever,  tuberculosis,  septicemia,  Bright's  disease,  gout,  scurvy,  dia- 
betes, and  with  pneumonia  and  pleuropneumonia,  particularly  in 
alcoholics.      Bacterial  infection  is  the  direct  cause. 

Pathological  Anatomy. — The  structural  changes  in  this  affection 
are  similar  to  inflammation  in  other  serous  membranes.  These 
changes  present  themselves  as  acute  plastic  or  dry  pericarditis,  or 
pericarditis  with  a  serofibrinous,  hemorrhagic,  or  purulent  effusion. 
The  earliest  change  is  that  of  hyperemia,  most  marked  on  the  visceral 
layer,  giving  it  a  dull  red  appearance,  which  is  followed  by  the  exuda- 
tion of  lymph  in  scattered  and  irregular  patches  causing  the  membrane 
to  appear  rough  and  shaggy  {dry  pericarditis).  Later,  there  is  an 
effusion  poured  out  which  may  be  serofibrinous,  hemorrhagic,  or 
purulent.  In  serofibrinous  pericarditis  the  effused  material  consists 
largely  of  straw-colored  fluid  which  varies  in  quantity  from  a  few 
ounces  to  i  or  2  pints  or  more.  The  extravasation  of  blood  into  the 
sac  from  any  cause  during  the  affection  gives  rise  to  the  hemorrhagic 
form,  and  the  purulent  variety  results  from  pyogenic  infection  of  the 
membrane.  When  the  serum  is  deficient  in  the  exudate  and  fibrin 
predominates,  the  effusion  is  extremely  scant  and  the  term  fibrinous 
pericarditis  is  applied.  Its  onset  is  less  acute  and  the  tendency  to 
form  adhesions  is  very  great.  Varying  grades  of  myocardial  inflam- 
mation are  encountered  in  combination  with  pericarditis. 


394  ACUTE   PERICARDITIS 

Symptoms. — Acute  pericarditis  may  be  well  marked  and  still 
present  none  of  the  characteristic  subjective  symptoms.  It  usually 
begins  with  rigors,  fever  of  the  remittent  type,  frequently  nausea  and 
vomiting,  precordial  distress  and  tenderness,  acute  shooting  pains,  in- 
creased by  breathing  and  coughing;  dry,  suppressed  cough;  increased 
cardiac  action,  and  sometimes  violent  palpitation.  An  attack  of 
pericarditis  secondary  to  an  existing  disease  presents  no  marked  symp- 
toms other  than  those  mentioned  to  indicate  its  onset.  Attacks  of 
nausea  and  vomiting  occurring  during  the  course  of  rheumatism, 
pneumonia,  pleurisy,  and  nephritis  should  always  call  attention  to 
the  heart.  The  duration  of  this  early  stage  is  from  a  few  hours  to 
a  day  or  two. 

During  the  stage  of  effusion,  the  symptoms  vary  with  the  amount  of 
effusion  and  the  rapidity  w^ith  which  it  is  formed.  There  are  pre- 
cordial oppression,  tendency  to  syncope,  dyspnea  at  times  amounting 
to  orthopnea,  dysphagia,  hiccough,  nausea,  vomiting,  feeble  irreg- 
ular pulse,  and  sometimes  melancholia,  delirium,  or  acute  maniacal 
excitement. 

Absorption  is  usually  rapid,  but  the  heart  remains  irritable  for  quite 
a  long  period.  If  absorption  does  not  occur  and  the  fluid  accumu- 
lates continuously  without  destroying  life  at  the  time,  the  pericardial 
sac  becomes  dilated,  and  chronic  pericarditis  is  produced. 

A  purulent  effusion  in  the  pericardial  sac  is  evidenced  by  irregular 
fever,  chills,  sweats,  and  leukocytosis  in  addition  to  the  symptoms 
already  given. 

Physical  Signs. — Inspection  during  the  early  stage  shows  excited 
cardiac  action  as  evidenced  by  the  impulse.  During  the  effusion 
stage,  the  impulse  is  feeble,  undulatory,  or  absent;  it  is  usually  dis- 
placed upward,  very  rarely  downward,  the  precordium  bulges,  and  the 
abdomen  protrudes  when  the  effusion  is  large. 

Palpation  during  the  early  stage  serves  to  detect  an  excited  or  tu- 
multuous impulse,  and  in  very  rare  instances  pericardial  friction  frem- 
itus. During  the  effusion  stage,  the  impulse  is  feeble  or  absent  and 
when  present  is  considerably  displaced.     Tenderness  may  be  elicited. 

Percussion  is  normal  in  the  beginning  of  the  disease  but  as  the 
effusion  forms  the  cardiac  dullness  becomes  enlarged  vertically  and 
laterally.  If  the  accumulation  of  fluid  is  considerable,  the  dullness 
assumes  a  triangular  shape  with  the  base  on  a  line  with  the  sixth  or 
seventh  rib  extending  from  the  right  of  the  sternum  to  the  left  of  the 
left  nipple  and  the  apex  at  the  sternal  attachment  of  the  second  rib 


ACUTE   PERICARDITIS  395 

or  higher.  The  shape  of  the  dullness  is  sometimes  altered  by  chang- 
ing the  position  of  the  patient. 

Auscultation  at  the  onset  reveals  excited  cardiac  action  and  usually 
an  exocardial  murmur  or  friction  sound,  synchronous  with  the  cardiac 
sounds  and  uninfluenced  by  respiration  but  often  increased  by  pres- 
sure with  the  stethoscope.  Later  as  the  effusion  forms,  the  cardiac 
sounds  are  feeble  and  deep-seated  at  the  apex,  becoming  louder  and 
distinct  toward  the  cardiac  base.  The  friction  sound  is  sometimes 
heard  at  the  base.  As  absorption  progresses,  the  friction  sound 
returns,  being  replaced  shortly  by  the  normal  heart  sounds. 

Diagnosis. — Acute  endocarditis  may  be  distinguished  from  acute 
pericarditis  by  the  absence  of  friction  sound  and  triangular  dullness 
and  by  the  presence  of  soft  systolic  or  diastolic  murmurs  heard  best 
over  one  of  the  valve  points. 

Cardiac  hypertrophy  is  unattended  by  acute  symptoms,  friction 
sound,  or  evidences  of  effusion.  The  onset  is  less  sudden.  The 
impulse  is  strong  and  the  sounds  are  loud. 

Cardiac  dilatation  is  characterized  by  enlargement  of  the  area  of 
dullness  downward,  undulatory  impulse,  and  clear  and  distinct  heart 
sounds.     There  is  no  friction  sound. 

Hydropericardium  is  attended  by  the  physical  signs,  common  to 
pericardial  effusion,  but  at  no  time  is  a  friction  sound  obtained  on 
examination.  The  history  of  other  dropsies  and  their  underlying 
diseases  aids  in  making  the  diagnosis. 

Prognosis. — This  is  controlled  by  the  severity  of  the  inflammation, 
its  causes,  and  the  coexisting  conditions.  Pericarditis  with  slight  effu- 
sion is  frequently  overlooked  and  often  terminates  favorably  with- 
out being  detected.  Simple  serofibrinous  pericarditis  without 
complications  and  under  proper  treatment  ends  in  recovery  in 
from  one  to  three  weeks.  In  debilitated  subjects  the  disease  is  pro- 
longed. The  rapid  effusion  of  large  quantities  of  fluid  may  cause 
sudden  death.  Purulent  effusions  are  usually  fatal.  Fibrinous 
pericarditis  is  attended  by  adhesions  and  subsequent  changes  in  the 
heart  muscle.     Relapses  are  not  infrequent. 

Treatment. — Absolute  rest  in  bed  with  mental  quiet  is  necessary. 
Death  has  followed  neglect  of  this  simple  precaution.  Milk  diet 
should  be  prescribed.  Local  applications  are  especially  valuable  in 
the  early  stage;  in  vigorous  patients  leeches  or  wet  cups  applied  to  the 
precordium  followed  by  ice-poultices  or  iced- compresses;  in  the  feeble 
and  debilitated,  dry  cups  to  the  precordium,  followed  by  poultices. 


396  ACUTE   PERICARDITIS 

Blisters  are  also  very  beneficial.  Cold  applications  by  means  of 
Leiter's  coil  or  ice-bags  are  sometimes  more  comfortable  than  the 
foregoing  procedures.  Occasionally  heat  is  more  serviceable.  The 
hypodermic  injection  of  morphine  sulphate,  gr.  yi  (0.0165  gm.), 
and  atropine  sulphate,  gr.  Hso  (0.00044  gn^.),  serves  to  relieve  pain 
and  quiet  the  heart. 

Mercury  is  often  of  value  in  relieving  the  gastrointestinal  symp- 
toms and  in  lessening  the  pericardial  inflammation.  The  following 
formula  is  employed  with  benefit: 

I^.     Hydrargyri  chloridi  mitis. .   gr.  3^  0.022  gm. 

Sodii  bicarbonat gr.  ij  o.  13    gm. 

Sacchar.  lactis gr.  ij  0.13    gm. 

M.  S. — To  be  taken  dry  on  the  tongue  every  two  hours  until 
free  action  of  the  bowels  is  obtained. 

The  late  Dr.  Pepper  recommended  the  following  combination: 

I^.     Pulv.  digitalis 

Mass.  hydrargyri aa  gr.  x  aa     0.6  gm. 

Pulv.  opii gr.  V  0.3  gm. 

Quininae  sulph gr.  xxx  2 .  o  gm. 

M.     Ft.  mass  et  div.  in  pil.  No.  xx. 
S. — One  pill  three  or  four  times  daily. 

In  young,  vigorous  patients,  the  excited  cardiac  action  may  be  con- 
trolled early  in  the  disease  by  small  doses  of  aconite  or  veratrum 
viride;^in  adults,  the  aged,  and  feeble  individuals,  digitalis,  in  doses 
sufficient  to  steady  the  heart,  but  not  to  stimulate  too  forcibly, 
should  be  employed.  Quinine,  strychnine,  alcohol,  and  ammonia 
are  of  value  in  all  cases.  In  secondary  cases,  except  those  due  to 
rheumatism,  cardiac  sedatives  should  be  avoided;  the  treatment 
recommended  for  the  primary  condition  should  be  continued  and 
combined  with  the  measures  indicated  for  the  pericarditis. 

During  the  stage  of  effusion,  the  diet  should  still  be  liquid,  and 
stimulants  should  be  continued  to  maintain  the  heart's  action.  Am- 
monium carbonate,  solution  of  ammonium  acetate,  potassium  ace- 
tate, potassium  carbonate,  quinine  sulphate,  and  saline  purgatives  are 
also  indicated.  Diuretics  may  be  employed  but  diaphoretics  such  as 
pilocarpine  are  contraindicaled.  If  the  effusion  gives  rise  to  marked 
pressure  symptoms,  tapping  should  be  performed  either  in  the  fossa 
between  the  ensiform  and  costal  cartilages  on  the  left  side,  or  in  the 


CHRONIC   PERICARDITIS  397 

fifth  left  interspace  near  the  junction  of  the  sixth  rib  with  its  carti- 
lage. Blisters  and  potassium  iodide  aid  in  absorption  of  the  exudate. 
When  the  exudate  is  purulent,  incision  of  the  chest  wall  and 
drainage  of  the  pericardial  sac  is  indicated.  The  toxemia  is  pro- 
found and  tonics  and  stimulants  should  be  given  very  freely, 

CHRONIC  PERICARDITIS 

Synonym. — Adhesive  pericarditis. 

Definition. — A  chronic  inflammation  of  the  pericardium,  with 
either  distention  of  the  sac  by  fluid,  or  adhesions  of  the  pericardium 
(adherent  pericardium) ;  characterized  by  impaired  cardiac  action  and 
disturbances  of  the  circulation. 

Cause. — The  affection  is  always  secondary  to  an  acute  attack. 

Pathological  Anatomy. — If  the  fluid  is  absorbed,  the  pericardial 
surfaces  become  agglutinated  by  several  layers  of  lymph,  which  serve 
to  increase  the  thickness  of  the  sac  wall  ^^  inch  or  more.  Often 
the  outer  surface  of  the  pericardium  becomes  adherent  to  the  chest 
walls.  If  the  fluid  is  not  absorbed,  it  may  continue  to  accumulate, 
distending  the  sac  in  all  directions,  displacing  the  diaphragm,  and 
interfering  with  the  functions  of  adjacent  viscera;  or  a  low  grade  of 
septic  inflammation  may  supervene  with  the  formation  of  a  purulent 
effusion  {empyema  of  the  pericardium),  the  disease  terminating  fa- 
tally after  a  varying  period. 

Symptoms. — Precordial  pain  and  distress  are  prominent  symptoms. 
Cardiac  action  is  irregular  and  feeble,  and  dyspnea,  worse  on  move- 
ment, with  other  signs  of  embarrassed  circulation  is  present.  When 
agglutination  of  the  walls  occurs,  there  arises  a  great  tendency  to 
pulmonary  inflammation. 

Physical  Signs. — Inspection  detects  bulging  of  the  precordium  and 
displacement  of  the  impulse  if  the  effusion  is  yet  present.  If  the 
pericardium  is  adherent  to  the  chest  wall,  depression  of  the  precordium 
and  recession  of  the  intercostal  spaces  {systolic  dimpling)  and  epigas- 
trium with  every  systole,  will  occur.  The  interspaces  are  narrowed 
and  the  impulse  is  more  diffuse  but  displaced  and  uninfluenced  by 
deep  inspiration. 

Palpation  serves  to  confirm  inspection.  In  the  presence  of  an 
effusion,  the  impulse  is  displaced  and  feeble  or  absent;  if  adhesions 
exist,  the  impulse  is  displaced  and  tumultuous.  A  friction  fremitus 
may  occasionally  be  obtained. 


398  HYDROPERICARDIUM 

Percussion  will  be  of  service  in  outlining  dullness  corresponding 
to  the  effusion,  if  any  is  present.  If  adhesions  only  exist,  the  cardiac 
dullness  is  but  slightly  modified. 

Auscultation  reveals  feeble  and  deep-seated  cardiac  sounds  at  the 
apex,  and  loud  and  more  distinct  sounds  at  the  base  if  there  is  any 
effusion.  If  adhesions  are  present  the  cardiac  sounds  are  unaltered 
and  a  rough  friction  sound  or  exocardial  murmur  may  be  obtained. 

Treatment. — The  cardiac  action  should  be  carefully  watched  and 
maintained  by  stimulants,  as  advised  in  the  acute  form.  Blisters, 
potassium  iodide,  purgation,  and  other  means  calculated  to  absorb 
inflammatory  exudates  should  be  employed.  Paracentesis  may  be 
necessary.     Incision  is  indicated  if  the  effusion  becomes  purulent. 

HYDROPERICARDIUM 

Sjmonjrm. — Pericardial  dropsy. 

Definition. — The  accumulation  of  fluid  in  the  pericardial  sac 
without  inflammation,  characterized  by  precordial  distress,  disturbed 
cardiac  action,  dyspnea,  and  dysphagia. 

Causes. — It  is  always  a  secondary  affection  being  due  to  heart 
disease,  Bright's  disease,  pneumothorax,  pressure  of  an  aneurysm 
or  other  mediastinal  tumor,  or  disease  of  the  cardiac  vein. 

Pathology. — ^A  pericardial  effusion  is  formed  without  any  evi- 
dences of  inflammatory  changes.  The  fluid  may  range  in  quantity 
from  an  ounce  to  i  or  2  pints  and  is  usually  clear,  yellowish,  and 
straw-colored  and  of  an  alkaline  reaction. 

Sjmiptoms. — Manifestations  of  dropsy  in  other  parts  of  the  body, 
or  anasarca,  will  be  observed.  The  pericardial  involvement  is 
indicated  by  disturbances  of  the  heart's  action,  dyspnea,  dysphagia, 
dry  cough,  and  other  signs  of  cardiac  embarrassment. 

Physical  signs  are  those  of  pericardial  effusion  from  other  causes; 
the  friction  sound,  however,  is  never  obtained. 

Diagnosis. — A  differentiation  between  this  affection  and  peri- 
carditis with  effusion  can  be  made  only  by  consideration  of  the  his- 
tory and  the  results  of  aspiration. 

Prognosis. — The  outlook  depends  entirely  upon  the  nature  of  the 
underlying  disease. 

Treatment. — The  effusion  calls  for  paracentesis  if  the  cardiac 
action  is  seriously  disturbed.  The  major  portion  of  the  treatment 
should  be  directed  toward  the  original  cause  of  the  dropsy.    . 


ACUTE   ENDOCARDITIS  399 

DISEASES  OF  THE  ENDOCARDIUM 

ACUTE  ENDOCARDITIS 

Synonyms. — Valvulitis;  exudative  endocarditis. 

Definition. — An  acute  fibrinous  inflammation  of  the  serous  mem- 
brane lining  the  cavity  of  the  heart  and  particularly  its  valves,  in 
severe  cases  the  chordae  tendineae  being  involved,  resulting  in  changes 
in  the  valves  or  orifices  of  the  heart,  or  both;  characterized  by  cough, 
dyspnea,  disturbed  cardiac  action,  nausea,  vomiting,  and  more  or 
less  marked  febrile  reaction.  Acute  endocarditis  occurs  in  two 
distinct  forms:  plastic  or  simple  exudative  endocarditis,  and  ulcerative 
or  diphtheritic  endocarditis.  The  ulcerative  form  is  considered 
under  a  separate  heading  (see  Malignant  Endocarditis). 

Causes. — ^Acute  simple  endocarditis  is  usually  secondary  to  some 
other  affection,  particularly  acute  articular  rheumatism  (especially 
in  young  people),  chorea,  pleurisy,  pneumonia,  pericarditis.  Bright 's 
disease,  and  the  infectious  fevers  such  as  scarlatina,  influenza,  and 
diphtheria.  Gonorrhea  is  an  occasional  cause.  Cachectic  states 
such  as  accompany  tuberculosis  and  cancer  are  predisposing  causes. 
It  may  be  secondary  to  chronic  endocarditis. 

Pathology. — Acute  simple  endocarditis  may  be  prenatal  as  well  as 
postnatal.  In  the  former  class  of  cases,  the  right  side  of  the  heart 
is  usually  involved,  while  in  those  instances  observed  after  birth,  the 
disease  is  most  often  limited  to  the  left  side.  While  the  disease  may 
attack  the  entire  lining  membrane  of  the  heart  it  is  especially  marked 
at  the  valvular  portions  of  the  endocardium.  The  earliest  change  is 
that  of  hyperemia  of  the  membrane  rendering  it  red  and  swollen.  As 
the  inflammatory  exudate  is  thrown  out  the  surface  of  the  valves 
becomes  roughened  and  warty  excrescences  are  formed.  These  ver- 
rucose  formations  are  to  be  found  on  the  auricular  surface  of  the 
mitral  valve  and  on  the  ventricular  surface  of  the  aortic  valve  at  the 
line  of  contact  of  their  leaflets,  usually  from  i  to  2  mm.  from  their  free 
margin.  These  vegetations  are  produced  by  a  proliferation  of  the 
cells  of  the  adventitia  and  of  the  external  connective  tissue;  fibrin 
from  the  blood  is  deposited  on  the  forpiations,  thus  serving  to  in- 
crease their  size.  The  excrescences  are  friable  and  may  be  easily  de- 
tached or  broken  off  and  carried  in  the  blood  stream  as  emboli,  to 
various  parts  of  the  body,  particularly  the  left  side  of  the  brain,  the 
kidneys,  and  the  spleen.  If  retained  in  position,  fibrous  tissue  is 
eventually  formed;   the  valves  become  thickened  and  contracted 


400  ACUTE    ENDOCARDITIS 

producing  chronic  endocarditis.  Tlie  leaflets  may  then  become  the 
seats  of  various  infiltrations. 

Symptoms. — Occurring,  as  it  does,  in  the  course  of  some  other 
disease  the  subjective  symptoms  of  acute  simple  endocarditis  are 
usually  masked  by  the  manifestations  of  the  primary  condition,  until 
disturbances  of  the  circulation  direct  attention  to  the  heart.  In- 
crease of  temperature,  precordial  distress,  cough,  slight  dyspnea,  and 
more  or  less  persistent  vomiting  may  be  present.  The  action  of  the 
heart  is  increased  and  often  tumultuous .  The  carotids  throb  and  there 
are  noises  in  the  ear.  As  the  inflammation  progresses,  the  cardiac 
action  and  pulse  become  less  frequent,  and  venous  stasis  and  more  or 
less  pulmonary  congestion  occur.  The  attack  lasts  from  one  to  three 
weeks. 

Physical  Signs. — Auscultation  reveals  a  change  in  the  character  of 
the  sounds  (prolongation)  and  sometimes  the  development  of  a  mur- 
mur corresponding  to  the  affected  valve. 

Diagnosis. — In  all  diseases  in  which  endocarditis  is  liable  to  occur, 
physical  examination  of  the  chest  should  be  made  at  frequent  inter- 
vals as  the  symptoms  are  by  no  means  distinctive  and  the  diagnosis 
is  made  largely  by  the  physical  signs. 

Pericarditis  is  distinguished  from  endocarditis  by  the  character  of 
the  physical  signs.  In  pericarditis,  the  murmur  or  friction  sound  is 
heard  with  either  cardiac  sound,  is  near  to  the  ear,  and  is  influenced  by 
pressure  of  the  stethoscope,  besides  being  associated  with  more  or  less 
alteration  in  the  size  and  shape  of  the  cardiac  dullness,  and  ic  not 
transmitted,  while  in  endocarditis  the  murmur  takes  the  place  of,  or  is 
associated  with,  the  cardiac  sounds,  and  is  transmitted  to  points 
beyond  the  precordium,  with  absence  or  change  in  size  and  form  of  the 
cardiac  dullness  on  percussion. 

Embolism  in  the  course  of  endocarditis  produces  an  additional 
group  of  symptoms,  the  presence  of  which  may  give  rise  to  confusion. 
Embolism  of  the  kidneys  causes  sudden,  deep-seated  lumbar  pain, 
with  albuminuria  and  even  hematuria ;  embolism  of  the  brain,  sudden 
palsies  and  sudden  disturbance  of  consciousness;  of  the  spleen,  sharp 
pain  arid  tenderness  in  the  splenic  region;  of  the  skin,  petechial  or 
purpuric  spots. 

Prognosis. — Acute  simple  endocarditis  without  complications  is 
not  dangerous  to  life,  but  the  affected  valve  usually  remains  damaged 
and  later  becomes  the  seat  of  chronic  endocarditis. 

Treatment. — Absolute  rest  in  bed  and  liquid  diet  are  essential. 


MALIGNANT   ENDOCARDITIS  4OI 

Leeches,  wet  cups,  ice,  or  poultices  applied  to  the  precordium  may  be 
of  value.  If  the  heart  is  weak  and  irregular,  digitalis  in  moderate 
doses  may  be  employed.  Purgation  by  salines  should  be  obtained 
early  in  the  disease.  The  free  administration  of  alkalies  such  as 
ammonium  carbonate,  potassium  carbonate,  and  potassium  acetate 
until  the  urine  is  alkaline,  may  serve  to  prevent  permanent  changes 
in  the  valves.  If  the  alkalies  fail  and  the  inflammation  shows  a 
tendency  to  linger,  mercury  should  be  administered.  Dyspnea  may 
usually  be  relieved  by  the  administration  of  opium  or  morphine.  If 
symptoms  of  embarrassment  of  the  circulation  appear  such  as  marked 
dyspnea,  cyanosis,  and  edema,  strychnine,  atropine,  nitroglycerin, 
digitalis,  ammonium  carbonate,  and  similar  heart  tonics  are  indicated. 
After  actue  symptoms  have  subsided  absorption  of  the  exudate  may 
be  brought  about  to  some  extent  by  the  free  use  of  potassium  iodide. 

MALIGNANT   ENDOCARDITIS 

Synonjmis. — Ulcerative  endocarditis;  septic,  mycotic,  and  diph- 
theritic endocarditis. 

Definition. — An  acute  septic  inflammation  of  the  lining  mem- 
brane of  the  heart,  with  a  strong  tendency  to  ulceration;  characterized 
by  depression  of  the  vital  forces  with  more  or  less  cardiac  distress. 

Causes. — Microorganismal  infection  is  the  primary  cause,  but  as 
yet  a  specific  organism  has  not  been  isolated.  It  may  follow  pneu- 
monia, erysipelas,  septicemia,  puerperal  fever,  influenza,  meningitis, 
gonorrhea,  or  acute  rheumatism. 

Pathological  Anatomy. — The  changes  are  those  of  acute  endocar- 
ditis up  to  the  development  of  the  thickening  of  the  endocardium 
lining  the  valves,  and  the  development  of  the  vegetations.  Instead 
of  the  poison  spending  its  force  and  the  chronic  condition  obtaining, 
a  process  of  softening,  ulceration,  development  of  abscesses,  and  per- 
foration of  leaflets  follows,  resulting  in  loss  of  structure,  general  septic 
infection,  and  the  development  of  emboli,  which  lead  to  infarctions  in 
the  brain,  kidney,  spleen,  eye  or  skin. 

Symptoms. — The  septic  intoxication  is  manifested  by  headache, 
restlessness,  delirium  of  varying  degrees,  dry  coated  tongue,  sordes 
on  the  lips  and  on  the  gums,  nausea,  vomiting,  constipation  or  diar- 
rhea, leukocytosis,  irregular  fevers,  rigors,  and  sweats.  The  heart's 
action  is  rapid,  irregular,  and  weak,  and  the  pulse  is  compressible. 
The  spleen  is  enlarged  and  albuminuria  is  present.  Paroxysmal 
dyspnea  and  cyanosis  are  common  symptoms.  The  patient  fre- 
26 


402  CHRONIC   ENDOCARDITIS 

quently  experiences  a  sense  of  impending  danger,  great  anxiety,  and 
terror.  The  occurrence  of  embolism  is  marked  by  additional  symp- 
toms referable  to  the  organ  affected.  If  the  embolism  occurs  in  the 
brain,  there  will  ensue  rapidly  developing  palsies  with  disorder  of 
consciousness;  if  in  the  kidneys,  deep-seated  lumbar  pains  with  hem- 
aturia or  disordered  urinary  flow;  if  in  the  spleen,  pain  and  tenderness 
of  the  splenic  region  with  increase  of  temperature  record. 

Physical  Signs. — Auscultation  reveals  the  replacement  of  the  nor- 
mal, booming,  muscular,  first  sound  by  a  feeble,  irregular  cardiac 
pulsation.  Generally  a  murmur  may  be  detected  but  it  is  subject 
to  great  variations,  and  m.ay  be  absent. 

Diagnosis. — This  is  extremely  difficult;  the  occurrence  of  septic 
phenomena  together  with  symptoms  of  cardiac  embarrassment  in 
the  course  of  various  affections  mentioned  under  causes,  is  highly 
suggestive. 

Typhoid  fever  is  less  acute;  the  fever  is  more  regular;  the  abdominal 
symptoms  are  more  marked;  a  roseolar  eruption  is  present,  the  leuko- 
cytes are  not  increased;  the  Widal  reaction  is  obtained;  and  typhoid 
bacilli  are  found  in  the  stools. 

Prognosis. — The  termination  is  almost  invariably  fatal  in  from 
one  to  eight  weeks  or  more. 

Treatment. — This  is  very  unsatisfactory.  Nutritious  food  and 
stimulants  such  as  quinine,  iron,  alcohol,  strychnine,  digitalis,  and 
nitroglycerin  should  be  freely  used  to  support  the  patient  and  to 
maintain  the  heart's  action.  Sponging  will  serve  to  reduce  the 
temperature  and  render  the  patient  more  comfortable.  Belladonna 
plaster  over  the  precordium  is  beneficial  but  other  applications  seem 
only  to  increase  the  distress.  Antistreptococcus  serum  (20  c.c. 
injected  daily)  has  been  employed  by  some  observers  with  success 
and,  considering  the  prognosis  of  this  affection,  it  is  worthy  of  a  fair 
trial. 

CHRONIC  ENDOCARDITIS 

Synonjmi. — Chronic  valvular  disease. 

Definition. — ^Alterations  in  the  cardiac  valves  or  orifices,  rendering 
the  former  incapable  of  properly  closing  the  orifices  (regurgitation), 
or  causing  the  narrowed  orifice  to  interrupt  the  blood  current  in  its 
normal  movement  (stenosis). 

Varieties. — I.  Mitral  regurgitation.  II.  Aortic  regurgitation. 
III.    Tricuspid   regurgitation.     IV.    Pulmonary   regurgitation.     V. 


MITRAL   REGURGITATION  403 

Mitral  obstruction.  VI.  Aortic  obstruction.  VII.  Tricuspid  ob- 
struction.    VIII.  Pulmonary  obstruction. 

Causes. — The  great  majority  of  cases  are  the  result  of  an  attack 
of  acute  endocarditis  following  rheumatism,  chorea,  or  the  infectious 
diseases.  A  chronic  endocarditis  from  the  onset  may  be  caused  by 
alcoholism,  syphilis,  gout,  or  excessive  muscular  labor.  Chronic 
Bright's  disease  is  also  an  exciting  cause.  In  elderly  people,  chronic 
endocarditis  may  often  be  due  to  atheromatous  or  fibroid  changes. 

Compensation. — The  alterations  in  the  systemic  blood  supply 
caused  by  the  valvular  defects  of  chronic  endocardial  inflammation 
are  such  that,  if  continued,  the  integrity  of  the  body  is  threatened. 
To  overcome  the  impaired  functions  of  the  valves  and  to  maintain 
the  general  circulation,  the  heart  increases  in  size  and  strength 
{compensatory  hypertrophy).  The  period  in  which  this  occurs  is 
called  the  period  of  compensation;  its  duration  is  indefinite.  It  may 
be  recognized  by  the  physical  signs  of  valvular  disease  without  any 
symptoms  of  disturbed  circulation.  Anything  which  disturbs  the 
equilibrium  as  it  now  exists,  such  as  acute  diseases  and  excessive 
work,  leads  to  ruptured  compensation,  a  condition  attended  by  cyano- 
sis, dyspnea,  edema,  gastric,  hepatic,  and  renal  disturbances,  and 
often  death.  The  object  in  the  treatment  of  all  forms  of  chronic 
valvulitis  is  to  obtain  compensation  and  to  prevent  its  failure  or 
rupture. 

MITRAL  REGURGITATION 

This  form  of  valvular  disease  is  also  termed  mitral  insufficiency, 
and  is  the  most  frequent  variety  of  valvular  heart  disease. 

Pathological  Anatomy. — The  most  common  conditions  observed 
are  more  or  less  contraction  and  narrowing  of  the  tongues  of  the 
valves,  with  irregular  thickening  and  rigidity;  atheroma  or  calci- 
fication of  the  segments;  laceration  of  one  or  more  segments;  adhe- 
sion of  one  or  more  segments  to  the  inner  surface  of  the  ventricle; 
thickened  and  stiffened,  or  ruptured,  chordce  tendinecB,  and  also 
contraction  and  hardening  of  the  musculi  papillares. 

As  a  result  of  the  regurgitation  or  leakage  of  the  blood  back  into 
the  left  auricle,  there  is  a  dilatation  of  the  auricle,  followed  by  slight 
cardiac  hypertrophy.  Ventricular  hypertrophy  occurs  after  a  time 
from  the  increased  number  of  the  cardiac  contractions.  If,  as  is 
eventually  the  case,  the  left  auricle  is  unable  to  overcome  the  back- 
ward flow  of  blood,  it  dilates  and  the  lungs  become  congested.     The 


404  AORTIC   REGURGITATION 

right  ventricle  is  then  forced  to  perform  more  work  and  hypertrophies. 
Hypertrophy  of  the  right  ventricle  is  followed  by  that  of  the  left 
ventricle.  In  the  event  of  its  failure  to  overcome  the  backward  flow, 
it  (right  ventricle)  also  dilates  and  the  tricuspid  valve  becomes 
insufficient  (see  Figs.  47  and  48). 

Symptoms. — Insufficiency  of  the  mitral  valves  soon  leads  to 
cardiac  hypertrophy,  in  order  to  compensate  for  the  diminished 
amount  of  blood  sent  onward  by  the  ventricular  systole.  This 
condition  causes  quickened  and  strong  pulse  with  some  shortness 
of  breath  on  severe  exertion.  When  compensation  ruptures,  it  is 
manifested  by  precordial  distress,  cough,  dyspnea,  feeble,  soft, 
rapid,  irregular  pulse,  pulmonary  congestion,  edema  of  the  limbs, 
ascites,  general  cyanosis,  hepatic  congestion,  and  scanty  and  albumin- 
ous urine;  all  of  which  symptoms  may  present  themselves  in 
varying  degrees.  When  extreme,  and  compensation  is  not  again 
brought  about,  death  is  the  result. 

Physical  Signs. — Inspection  shows  displacement  of  the  apex  beat 
downward  and  to  the  left.  In  children  and  youths,  bulging  of  the 
precordium  and  increased  cardiac  impulse  are  present.  In  emaciated 
individuals,  an  auricular  impulse  may  be  observed  to  the  left  of  the 
pulmonic  area  in  the  second  interspace. 

Palpation  serves  to  confirm  inspection.  The  displaced  cardiac 
impulse  is  forcible  and  diffused  in  the  early  stage;  as  compensation 
fails,  the  impulse  becomes  feeble  or  absent. 

Percussion  shows  an  increase  in  the  area  of  cardiac  dullness  trans- 
versely and  vertically. 

Auscultation  reveals  a  systolic  or  blowing  murmur,  heard  best  in 
the  mitral  area  and  transmitted  to  the  apex,  left  axilla,  and  under 
the  angle  of  the  scapula.  It  may  occur  with,  or  take  the  place  of  the 
first  sound  of  the  heart,  the  second  sound  being  markedly  accentu- 
ated, particularly  in  the  pulmonic  area. 

Prognosis. — So  long  as  the  compensating  hypertrophy  can  be 
maintained,  the  prognosis  is  not  unfavorable;  when  dilatation  super- 
venes, however,  the  patient  soon  perishes,  either  from  congestion 
of  the  lungs,  or  dropsy  and  exhaustion  (and  see  page  415). 

AORTIC  REGURGITATION 

This  is  also  termed  aortic  insufficiency  ^  and  occurs  next  in  fre- 
quency to  mitral  insufficiency.  It  is  the  most  serious  of  the  ordinary 
valvular  lesions. 


AORTIC   REGURGITATION  405 

Pathological  Anatomy. — The  valves  or  segments  adhere  to  the 
walls  of  the  aorta,  or  a  segment  is  lacerated  or  perforated,  or,  more 
commonly,  the  segments  are  shrunken,  deformed,  and  rigid,  permit- 
ting regurgitation  of  the  blood.  These  deficiencies  are  usually  associ- 
ated with  more  or  less  dilatation  of  the  orifice. 

The  inability  of  the  aortic  valves  to  completely  close  the  aortic 
orifice  at  the  proper  moment  allows  the  blood  that  should  go  onward 
to  flow  back  into  the  left  ventricle,  and  the  normal  flow  of  blood 
from  the  left  auricle  continuing,  causes  overfilling  of  the  ventricle, 
which  results  in  a  dilatation  of  its  cavity,  and  the  extra  effort  of  the 
ventricle  to  empty  itself  results  in  hypertrophy  of  the  walls.  In  no 
other  condition  does  the  dilatation  and  hypertrophy  of  the  cardiac 
walls  reach  such  a  degree.  The  older  writers  named  this  enormous 
enlargement  of  the  heart  ^^ cor  bovinum"  (see  Fig.  51). 

Symptoms. — So  long  as  the  cardiac  hypertrophy  is  just  sufficient 
to  compensate  for  the  valvular  condition,  there  are  no  symptoms, 
but  as  the  muscle  walls  continue  to  increase  symptoms  of  cardiac 
hypertrophy  present  themselves,  such  as  forcible  cardiac  action, 
with  marked  pulsation  of  all  the  vessels  including  the  capillaries, 
the  characteristic  forcible  and  receding  pulse  (''water-hammer 
pulse,"  or  "Corrigan  pulse"),  headache,  insomnia,  tinnitus  aurium, 
congestion  of  the  eyes  and  face,  etc.  Precordial  pain  is  usually 
present  in  aortic  disease.  It  may  be  a  sensation  of  constriction  in 
the  cardiac  region  or  it  may  consist  of  sharp,  shooting  pains  extending 
to  the  arms — anginoid  attacks.  As  soon  as  the  slightest  failure  of 
compensation  occurs,  the  cardiac  action  becomes  excessive  and  dis- 
tressing. Palpitation  is  present  and  causes  anxiety  and  fear  on  the 
part  of  the  patient.  When  there  is  complete  rupture  of  compensa- 
tion, there  develop,  either  gradually  or  rapidly,  dyspnea  (which  is 
increased  on  exertion),  cough,  cyanosis,  hepatic  enlargement,  renal 
congestion  with  scanty,  albuminous  urine,  ascites,  and  dropsy.  .  If 
mitral  insufficiency  is  now  superadded,  general  venous  stasis  and 
death  rapidly  follow.  Sudden  death  is  most  frequent  in  this  form 
of  vavular  heart  disease. 

Physical  Signs. — Inspection  shows  that  the  cardiac  impulse  is 
forcible  and  displaced  downward  and  to  the  left.  The  pulsation  is 
visible  far  beyond  the  normal  apex. 

Palpation  confirms  inspection.  It  may  at  times  serve  to  detect 
a  diastolic  thrill  over  the  base  of  the  heart  and  the  adjacent  large 
vessels.  The  Corrigan  pulse  and  the  capillary  pulse  are  recognized 
by  palpation. 


4o6 


AORTIC   REGURGITATION 


V     V        V     V 


''Systole.  Diastole. 

Trlcuspidl  Tricuspid 

Mitral       r^^'^nitral        ^P'" 
Aortic      )  Aortic      ^ 

PuUonaryr^"  PuLmonary  P^'^^ 


Pig.  44. — Position  of  the  valves;  in 
systole  and  diastole.  {From  Greene's 
Medical  Diagnosis.) 


Fig.  45. — The  normal  heart  in  systole. 
The  full  ventricles  are  contracting,  the 
blood  flows  freely  from  them  into  _  the 
pulmonary  artery  and  aorta;  the  mitral 
and  tricuspid  valves  are  tightly  closed; 
the  auricles  are  refilling.  {From  Greene's 
Medical  Diagnosis.) 


Fig.  46. — The  normal  heart  in  dias- 
tole. The  ventricular  contraction  has 
ceased,  the  aortic  and  pulmonary  valves, 
tightly  closed,  are  shutting  off  and 
supporting  the  blood  column;  the 
ventricles  are  filling  from  the  open 
mitral  and  tricuspid  orifices  above. 
{From  Greene's  Medical  Diagnosis.) 


Fig.  47. — 'Mitral  and  tricuspid  regur- 
gitation.— Heart  in  systole.     Mitral  and 
tricuspid  valves  both  incompetent.     Re- 
sult.— Double  systolic  murmur,  enlarge- 
ment of  both  right  and  left  chambers, 
pulsating  jugulars,  general  venous  con- 
gestion,   edema,    anasarca,    etc.     {From 
Greene's  Medical  Diagnosis.) 
M    V.   Mitral    valve,     t    v.    Tricuspid    valve.     A  v.  Aortic  valve.    P  '^.  Pulmonary 
valve.     L  A.  Left   auricle.     R.  A.  Right  auricle.     L  V.  Left  ventricle.     R.  V.  Right 
ventricle.    V  C  S.  Vena  cava  superior.    V  C  I.  Vena  cava  inferior.     P  Vn.   Pulmonary 
veins.    P  A.  Pulmonary  artery.    A  O.  Aorta. 


AORTIC   REGURGITATION 


407 


Fig.  48. — -Mitral  regurgitation.  Four 
varieties  of  the  murmur  of  mitral  regur- 
gitation are  shown  graphically.  The 
heart  in  systole,  mitral  leakage  evident. 
The  contracting  ventricles  are  forcing 
the  blood  through  the  open  aortic  and 
pulmonary  valves;  the  tricuspid,  tightly 
closed,  prevents  regurgitation  into  right 
auricle.  The  leaky  mitral  allows  back- 
flow  into  the  left  auricle  already  filling 
from  the  pulmonary  veins  above.  Re- 
sults.— A  systolic  murmur,  dilatation  of 
left  auricle,  pulmonary  congestion,  and 
consequent  enlargement  of  right  ven- 
tricle. {From  Greene's  Medical 
Diagnosis.) 


Fig.  49. — Graphic  representation  of 
three  varieties  of  the  murmur  of  mitral 
obstruction.  Heart  at  moment  of 
auricular  contraction  immediately  before 
systole  (presystole) ;  mitral  obstruction 
evident;  aortic  and  pulmonary  valves 
closed;  tricuspid  freely  opened;  right 
auricle  nearly  empty;  right  ventricle 
filled;  left  auricle  but  partly  emptied; 
left  ventricle  barely  half  full.  Result. — 
Presystolic  or  diastolic  murmur,  dilata- 
tion of  left  auricle,  congestion  of  lungs, 
consecutive  enlargement  of  right  heart. 
(From  Greene's  Medical  Diagnosis.) 


Fig.  so. — Aortic  stenosis.  Three 
varieties  of  the  aortic  systolic  murmur 
are  represented  graphically.  Diagram- 
matic representation  of  the  heart  in  sys- 
tole, stenosis  of  the  aortic  valve  being 
present;  the  mitral  and  tricuspid  valves 
have  closed;  the  right  ventricle  is  nearly 
empty;  the  left  ventricle  is  still  more 
than  half  full  of  blood,  because  of  the 
obstruction  present  at  the  aortic  orifice. 
Result. — A  systolic  murmur  in  the  aortic 
area;  enlargement  of  left  ventricle,  etc. 
(From  Greene's  Medical  Diagnosis.) 


Fig.  51. — Graphic  representation  of 
murmur.  Two  varieties  of  aortic  diasto- 
lic murmur  shown  graphically.  The  heart 
is  shown  in  diastole,  aortic  leakage  being 
evident.  The  blood  has  just  been  pro- 
jected into  the  aorta  and  pulmonary 
artery  by  the  ventricular  contraction. 
The  pulmonary  valve  tightly  closed 
maintains  the  blood  column,  but 
through  the  leaky  aortic  valve  a  regur- 
gitant current  meets  the  stream  descend- 
ing from  above  through  the  open  mitral 
valve.  _  Results. — A  diastolic  murmur, 
dilatation,  and  hypertrophy  of  left  ven- 
tricle, a  slapping,  low-tension  pulse. 
(From  Greene's  Medical  Diagnosis.) 


4o8  AORTIC   REGURGITATION 

Percussion  serves  to  demonstrate  an  increase  in  the  area  of  cardiac 
dullness  downward  and  to  the  left.  Occasionally  it  is  increased 
upward  and  to  the  left  of  the  sternum  as  the  result  of  hypertrophy 
of  the  left  auricle. 

BRAIN  ' 


CAPILLARIES 

Fig.  52. — Diagram  for  studying  the  results  of  backward  pressure.  Note  the  areas  in 
blue  will  become  the  seat  of  changes  consequent  on  venous  congestion.  {From  Wheeler 
and  Jack.) 

Auscultation  reveals  characteristic  alterations  in  the  heart  sounds. 
The  first  sound  is  forcible;  the  second  sound  is  replaced  or  associated 
with  a  churning,  rushing,  or  blowing  murmur  of  low  pitch,  well 
heard  at  the  second  right  costal  cartilage  (aortic  area)  but  most 
distinct  at  the  junction  of  the  sternum  and  the  fourth  left  costal 
cartilage.     It  is  diastolic  in  time  and  is  transmitted  downward  and 


TRICUSPID    REGURGITATION  409 

toward  the  apex.     A  presystolic  rumbling  murmur  {Flint  murmur) 
may  occasionally  be  heard  over  a  limited  area  at  the  apex. 

Prognosis. — Sudden  death  is  more  liable  to  occur  in  this  than  in 
any  other  form  of  chronic  valvular  disease.  So  long,  however,  as 
the  compensating  hypertrophy  is  intact,  it  is  compatible  with  quite 
an  active  life.  The  outlook  is  largely  influenced  by  the  condition 
of  the  arterial  walls.  Obstruction  from  any  cause  induces  rupture 
of  compensation.  Next  to  the  tricuspid  regurgitation  it  is  the  most 
serious  of  all  chronic  valvular  conditions.  Overexertion  influences 
it  unfavorably  (and  see  page  415). 

TRICUSPID  REGURGITATION 

Pathological  Anatomy. — This  form  of  valvular  insufficiency  is 
either  associated  with  right-sided  cardiac  dilatation  from  pulmonary 
obstruction,  or  is  the  result  of  mitral  disease.  The  tricuspid  orifice 
is  dilated  in  the  majority  of  cases;  occasionally  the  segments  of  the 
valves  are  contracted  or  adherent  to  the  ventricle.  It  may  be  due 
to  prenatal  endocarditis  or  to  endocarditis  in  childhood  (see  Fig.  47). 

Symptoms. — The  manifestations  of  this  condition  are  all  the  result 
of  venous  stasis,  and  include  jugular  pulsation  synchronous  with 
the  heart's  action,  hepatic,  renal,  and  pulmonary  congestion,  pulsa- 
tion o*f  the  liver,  cyanosis,  dyspnea,  and  obstinate  dropsy.  These 
symptoms  are  superadded  to  those  of  the  primary  or  associated 
conditions. 

Physical  Signs. — Inspection  detects  a  diffused,  wavy,  cardiac 
impulse,  synchronous  with  the  heart's  action  and  uninfluenced  by 
respiration,  more  or  less  prominent  hepatic  pulsation,  cyanosis, 
dyspnea,  and  edema. 

Palpation  shows  the  cardiac  impulse  to  be  feeble  and  extended 
downward. 

Percussion  reveals  hypertrophy  of  the  right  ventricle  as  is  evi- 
denced by  the  increased  area  of  cardiac  dullness  to  the  right  of  and 
below  the  sternum. 

Auscultation  serves  to  elicit  a  blowing  systolic  murmur  most  in- 
tense  at  the  junction  of  the  fourth  and  fifth  ribs  with  the  sternum. 
It  is  distinct  over  the  xiphoid  appendix  becoming  feeble  or  lost  in 
the  left  axillary  region.  It  is  often  associated  with  a  mitral  systolic 
murmur.     The  pulmonary  second  sound  is  weak. 

Prognosis. — This   is   the   most   unfavorable   variety   of   chronic 


4IO  PULMONARY  REGURGITATION 

valvular  disease  of  the  heart.  Dropsy,  dyspnea,  and  cyanosis 
persist  in  spite  of  treatment.  The  failure  to  restore  compensation 
results  in  death  (and  see  page  415). 

PULMONARY  REGURGITATION 

Pathological  Anatomy. — Insufficiency  of  the  pulmonary  valves 
is  of  rare  occurrence,  but  when  present,  the  changes  correspond,  more 
or  less,  with  those  described  under  aortic  regurgitation. 

Symptoms. — Most  of  the  symptoms  are  referable  to  dilatation 
of  the  right  side  of  the  heart  and  consequent  pulmonary  congestion, 
such  as  dyspnea,  cyanosis,  distention  of  the  superficial  vessels, 
palpitation  of  the  heart,  precordial  distress,  suffocative  attacks,  and 
dropsy. 

Physical  Signs. — Percussion  shows  extension  of  the  cardiac  dull- 
ness to  the  right  of  the  sternum. 

Auscultation  reveals  a  loud  blowing  diastolic  murmur  most  distinct 
at  the  junction  of  the  third  left  costal  cartilage  and  the  sternum. 

Prognosis. — Death  results,  sooner  or  later,  from  dropsy  and  exhaus- 
tion (and  see  page  415). 

MITRAL  OBSTRUCTION 

Mitral  obstruction  or  stenosis  is  not  so  frequent  as  regurgitation, 
and  is  very  often  associated  with  the  latter.  It  may  be  encountered 
as  a  single  affection  in  young  persons,  especially  females.  It  may 
be  due  to  acute  or  chronic  endocarditis,  or  it  may  occasionally  be 
congenital. 

Pathological  Anatomy. — Mitral  stenosis  is  caused  by  deposits 
around  the  orifice,  or  else  the  segments  of  the  valves  are  ''glued 
together  by  their  margins,"  leaving  but  a  funnel-shaped  opening, 
the  so-called  "buttonhole"  mitral  valve.  Vegetations  on  the  valves 
lead  to  more  or  less  obstruction  to  the  blood  current  (see  Fig,  49) . 

Symptoms. — The  obstructed  mitral  orifice  gives  rise  to  hyper- 
trophy of  the  left  auricle  which  in  time  is  followed  by  dilatation. 
The  symptoms  are  usually  unobservable  until  compensation  rup- 
tures, which  is  manifested  by  small,  irregular,  and  feeble  pulse, 
dyspnea,  cough,  bronchorrhea,  and  dilatation  of  the  right  side  of  the 
heart  soon  leading  to  general  venous  stasis,  dropsy,  and  death. 

Physical  Signs. — Inspection  shows  nothing  abnormal  until  hyper- 
trophy of  the  left  auricle  occurs  when  an  undulatory  impulse  is 


AORTIC    OBSTRUCTION  411 

observed  over  its  area.  Bulging  over  the  lower  part  of  the  sternum 
may  be  present. 

Palpation  serves  to  recognize  a  presystolic  thrill  near  the  apex 
(in  the  fourth  or  fifth  interspace  within  the  nipple-line).  When 
cardiac  dilatation  occurs,  a  diffused,  feeble,  and  irregular  cardiac 
impulse  is  felt  near  the  xiphoid  appendix. 

Percussion  may  demonstrate  increased  area  of  cardiac  dullness 
on  the  right  side. 

Auscultation  elicits  nothing  abnormal  in  the  first  or  the  second 
sound  except  possibly  disturbances  of  rhythm.  A  blowing,  some- 
times rasping,  sound  is  heard,  immediately  after  the  second  sound, 
and  immediately  before  the  first  sound  begins,  which  is  especially 
characteristic.  This  presystolic  murmur  is  heard  most  distinctly  in 
the  mitral  area  lessening  in  intensity  toward  the  base.  It  is  not 
transmitted  but  is  occasionally  heard  in  atypical  regions  such  as  the 
axilla  and  the  angle  of  the  scapula.  The  second  sound  in  the  pul- 
monary area  is  accentuated.  As  the  condition  reaches  its  terminal 
stage,  the  murmur  may  disappear  and  the  first  sound  becomes  snappy 
in  character.  With  the  onset  of  dilatation  all  the  heart  sounds 
become  enfeebled. 

Prognosis. — The  outlook  depends  upon  whether  auricular  hyper- 
trophy occurs  and  how  long  it  is  maintained.  Under  favorable 
circumstances  mitral  stenosis  is  compatible  with  a  long  and  rather 
active  life  (and  see  page  415). 

AORTIC  OBSTRUCTION 

Pathological  Anatomy. — Stenosis  of  the  aortic  orifice  is  caused  by 
the  projection  of  the  valves  inward,  and  their  becoming  rigid  and 
thickened,  atheromatous  or  calcareous,  so  that  they  cannot  be  pressed 
back  by  the  blood,  but  remain  constantly  in  the  current  of  the  circu- 
lation. Occasionally  the  valves  are  covered  with  fibrinous  masses, 
the  opening  into  the  artery  being  thus  more  or  less  completely  closed, 
or  the  segments  may  be  adherent  by  their  lateral  surfaces,  leaving  a 
central  opening,  which  may  be  so  contracted  as  to  permit  the  passage 
of  only  the  smallest  probe.  Aortic  stenosis  is  nearly  always  a  disease 
of  advanced  life,  and  is  associated  with  the  arterial  changes  of 
age.  Uncomplicated  cases  are  rare.  Aortic  disease  is  not  nearly  so 
often  of  rheumatic  origin  as  mitral  disease  (see  Fig.  50). 

Symptoms. — Hypertrophy  of  the  left  ventricle  rapidly  supervenes 


412  TRICUSPID    OBSTRUCTION 

Upon  aortic  stenosis,  and  so  long  as  the  cardiac  hypertrophy  is  just 
sufficient  for  compensation,  there  will  be  no  subjective  symptoms, 
many  cases  of  stenosis  being  discovered  only  when  the  individual  is 
examined  for  insurance  or  other  purposes.  The  pulse  is  small,  slow, 
and  hard.  When,  however,  the  compensatory  hypertrophy  begins 
to  fail,  the  supply  of  blood  to  the  brain  is  insufficient  in  many  cases, 
and  pallor,  with  attacks  of  vertigo,  syncope,  or  slight  epileptiform 
seizures  occur;  finally,  as  dilatation  of  the  left  ventricle  and  incompe- 
^tence  of  the  mitral  valve  result,  there  occur  pulmonary  congestion, 
dyspnea,  and  general  venous  stasis,  the  pulse  being  soft  and  feeble. 

Physical  Signs. — Inspection  serves  to  detect  displacement  of  the 
apex  beat  downward  and  to  the  left  varying  with  the  degree  of 
hypertrophy. 

Palpation  confirms  inspection.  The  impulse  is  strong  in  the  early 
stage,  becoming  feeble  with  the  onset  of  dilatation. 

Percussion  shows  a  slight  increase  in  the  cardiac  dullness. 

Auscultation  reveals  characteristic  changes  in  the  heart-sounds. 
The  first  sound  of  the  heart  is  replaced  or  associated  with  a  harsh, 
rasping  sound,  whistling  at  times,  having  its  greatest  intensity  at 
the  junction  of  the  second  right  costal  cartilage  with  the  sternum, 
transmitted  along  the  vessels;  the  murmur  may  sometimes  be  heard 
a  short  distance  from  the  patient.  Usually,  aortic  stenosis  is  associ- 
ated with  more  or  less  aortic  regurgitation,  whence  a  double  murmur 
occurs,  having  its  greatest  intensity  at  the  base  of  the  heart,  the  so- 
called  to-and-fro,  or  see-saw  murmur. 

Prognosis.— So  long  as  compensation  is  maintained  the  condition 
of  the  patient  is  comfortable,  if  a  quiet  life  be  followed.  When  the 
compensation  is  ruptured,  the  usual  symptoms  of  dilatation,  venous 
stasis,  and  dropsy  soon  ensue  (and  see  page  415). 

TRICUSPID  OBSTRUCTION 

This  condition  is  one  of  the  rarest  affections  of  the  heart,  and  if  it 
ever  does  occur  with  or  following  an  attack  of  endocarditis,  the  ana- 
tomical changes  are  similar  to  those  of  mitral  obstruction.  It 
produces  enlargement  of  the  heart  transversely  and  is  indicated  by  a 
presystolic  murmur  at  the  base  of  the  ensiform  cartilage.  This 
condition  soon  leads-  to  auricular  dilatation;  venous  stasis  rapidly 
supervenes,  associated  with  venous  pulsations  similar  to  those 
described  when  speaking  of  tricuspid  regurgitation. 


COMBINED  VALVULAR   LESIONS  413 

PULMONARY  OBSTRUCTION 

Pathological  Anatomy. — Pulmonary  obstruction  is  always  a  con- 
genital malady  and  may  be  found  associated  with  constriction  of 
the  pulmonary  artery,  patulous  foramen  ovale,  patulous  ductus 
Botalli,  or  stricture  of  the  ductus  Botalli.  Hypertrophy  of  the  right 
ventricle  may  ensue.  Those  in  whom  these  congenital  cardiac  condi- 
tions occur  are  otherwise  weak,  develop  slowly,  have  flabby  tissues 
and  soft  bones,  and  seem  poorly  nourished. 

Symptoms. — The  hypertrophy  which  often  occurs  serves  to  es- 
tablish compensation,  failure  of  which  as  in  other  valvular  defects 
results  in  cough,  dyspnea,  cyanosis,  and  death.  The  physical  signs 
reveal  marked  enlargement  of  the  right  ventricle  and  a  systolic 
murmur  in  the  second  left  intercostal  space  which  is  not  transmitted, 
and  a  systolic  thrill  in  the  pulmonary  area. 

Prognosis. — The  duration  of  these  congenital  affections  is  short, 
usually  from  a  few  days  to  a  few  months;  although  several  well- 
authenticated  cases  record  a  much  longer  duration  (and  see  page  415). 

RELATIVE  FREQUENCY  OF  VALVULAR  DEFECTS 

The  order  of  frequency  is  thus  given  by  F.  J.  Smith: 

1.  Mitral  incompetency. 

2.  Mitral  stenosis. 


,         Of  practically  equal  frequency. 

3.  Aortic   mcompetency.  J 

4.  Aortic  stenosis. 

5.  Tricuspid  stenosis. 

6.  Tricuspid  incompetency. 

7.  Pulmonary  stenosis. 

8.  Pulmonary  incompetency. 


COMBINED  VALVULAR  LESIONS 

Smith's  list  is  as  follows: 

1.  Aortic  incompetency  and  stenosis;  mitral  incompetency. 

2.  Aortic  stenosis  and  mitral  incompetency. 

3.  Aortic  incompetency  and  mitral  incompetency. 

(There  is  less  than  i  per  cent,  difference  in  the  frequency  of 
2  and  3.) 


414  DIAGNOSIS,   PROGNOSIS,   AND   TREATMENT 

4.  Aortic  incompetency  and  stenosis,  with  mitral  stenosis  and 

incompetency. 

5.  Mitral  incompetency  and  tricuspid  incompetency. 

6.  Aortic  incompetency  and  stenosis,  with  mitral  incompetency 

and  tricuspid  incompetency. 

DIAGNOSIS,  PROGNOSIS,  AND  TREATMENT  OF 
VALVULAR  DISEASES 

In  making  a  differential  diagnosis  between  the  various  forms  of 
valvular  disease  of  the  heart,  strict  attention  must  be  paid  to  the 
points  of  greatest  intensity  at  which  the  several  murmurs  are  heard. 

A  murmur  occurring  with  or  taking  the  place  of  the  first  sound 
of  the  heart — the  ventricular  systole — heard  most  distinctly  at  the 
apex,  transmitted  to  the  left  axilla  and  to  the  inferior  angle  of  the 
scapula — a    mitral    systolic    murmur — signifies    mitral   regurgitation. 

A  murmur  occurring  with  or  taking  the  place  of  the  first  sound 
of  the  heart,  with  its  point  of  greatest  intensity  at  the  xiphoid  appen- 
dix— a   tricuspid  systolic   murmur — signifies   tricuspid  regurgitation. 

A  murmur  heard  with  the  first  sound  of  the  heart,  high-pitched, 
rasping,  or  grating  in  character,  with  its  point  of  greatest  intensity 
at  the  second  right  costal  cartilage — an  aortic  systolic  murmur — 
signifies  aortic  obstruction. 

A  murmur  heard  with  the  first  sound  of  the  heart,  soft  in  character, 
with  its  point  of  greatest  intensity  at  the  junction  of  the  third  left 
costal  cartilage  with  the  sternum — a  pulmonic  systolic  murmur — • 
signifies  pulmonary  obstruction. 

A  murmur  occurring  immediately  after  the  second  sound  and 
immediately  before  the  beginning  of  the  first  sound  of  the  heart — 
a  presystolic  mitral  murmur — signifies  mitral  obstruction. 

A  murmur  heard  with  or  taking  the  place  of  the  second  sound  of 
thef  heart,  most  distinct  at  the  second  costal  cartilage,  to  the  right  of 
the  sternum,  and  well  transmitted  toward  the  apex  or  below — an 
aortic  diastolic  murmur — signifies  aortic  regurgitation. 

Although  eight  distinct  valvular  murmurs  have  been  described 
as  occurring  in  the  heart,  those  on  the  right  side  are  of  rare  occurrence, 
and  hence  of  little  clinical  importance. 

If  a  murmur  be  heard  with  the  first  sound  of  the  heart,  it  is  almost 
certainly  aortic  obstructive  or  mitral  regurgitant;  and  if  heard  with  the 
second  sound,  it  is  probably  aortic  regurgitant.     A  presystolic  mitral 


OF  VALVULAR   DISEASES  415 

murmur  is  also  of  comparatively  rare  occurrence,  the  force  with 
which  the  blood  passes  from  the  left  auricle  into  the  left  ventricle 
being,  under  ordinary  circumstances,  insufficient  to  excite  sonorous 
vibrations. 

Functional  or  hemic,  or  anemic  murmurs  may  be  confounded  with 
the  various  forms  of  valvular  disease  of  the  heart.  The  chief  points 
of  distinction  between  them  are  that  a  hemic  murmur,  which  is  always 
heard  at  the  base  of  the  heart,  is  always  systolic  in  time,  not  trans- 
mitted away  from  the  heart,  and  is  soft  in  character,  low  in  pitch, 
and  of  variable  intensity,  now  being  heard,  now  entirely  absent. 

Prognosis. — Broadbent  gives  the  following  points,  which  should  be 
considered  before  a  prognosis  is  given  in  any  valvular  lesion: 

1.  The  valve  affected  and  the  danger  attaching  to  the  particular 

lesion. 

2.  The  extent  of  the  lesion. 

3.  The  stationary  or  progressive  character  of  the  lesion. 

4.  The  degree  of  soundness  and  vigor,  functional  and  nutritional, 

of  the  muscular  substance  of  the  heart,  of  the  arterial  walls, 
and  of  the  tissues  generally. 

5.  The  age  of  the  patient. 

6.  The  family  history. 

7.  The  habits  and  mode  of  hfe  of  the  patient. 

8.  The  presence  or  absence  of  other  diseases. 

Treatment. — There  is  no  special  treatment  for  each  individual 
form  of  valvular  heart  disease.  According  to  DaCosta,  the  follow- 
ing should  govern  the  treatment: 

(i)  The  state  of  the  heart-muscle  and  of  the  cavities.  (2)  The 
rhythm  of  the  heart-action.  (3)  The  condition  of  the  arteries  and 
veins  and  of  the  capillary  system.  (4)  The  probable  length  of  exist- 
ence of  the  malady  and  its  likely  cause.  (5)  The  general  health.  (6) 
The  secondary  results  of  the  cardiac  affection. 

For  practical  ptirposes,  it  may  be  considered  that  if  the  apex- 
beat  is  not  displaced,  cardiac  dullness  is  not  enlarged  to  the  right  of 
the  sternum,  and  dyspnea  is  not  present,  medication  is  not  indicated 
and  may  even  be  injurious.  If,  on  the  other  hand,  symptoms  of 
hypertrophy,  dilatation,  or  failure  of  compensation  of  the  heart  are 
present,  treatment  should  be  instituted  at  once. 

In  all  cases,  however,  the  patient  should  be  warned  against  excess- 
ive physical  exertion  such  as  rapid  walking  or  running,  ascending 
stairs  quickly,  excessive  work,  etc.,  extremes  of  passion,  exposure  to 


4l6  DIAGNOSIS,  PROGNOSIS,   AND   TREATMENT 

cold  and  wet,  and  irregular  living.  The  occurrence  of  acute  diseases 
in  the  course  of  valvular  defects  cause  them  to  become  serious 
affections  and  every  means  should  be  taken  to  prevent  them.  The 
Nauheim  treatment,  Oertel's  method,  and  Swedish  movements  may- 
be of  great  value  during  the  compensation  stage. 

The  special  therapeutic  measures  indicated  for  cardiac  hyper- 
trophy and  cardiac  dilatation  are  considered  under  those  conditions. 
If  the  hypertrophy  necessary  to  maintain  compensation  becomes 
excessive,  aconite,  veratrum  viride,  or  nitroglycerin  is  indicated. 
If  dilatation  has  occurred,  the  heart's  action  is  weak  and  feeble,  the 
circulation  is  impeded,  and  venous  stasis  has  followed,  digitalis, 
caffeine,  strophanthus,  and  sparteine  together  with  more  or  less 
active  purgation  are  indicated.  Rest  is  of  value  in  all  cardiac 
conditions.  When  compensation  fails,  rest  is  an  absolute  indication. 
The  diet  should  be  liquid,  preferably  milk,  as  the  passive  congestion 
of  the  entire  digestive  tract  interferes  greatly  with  assimilation. 
The  heart  balance  is  best  restored  by  the  administration  of  some 
preparation  of  digitalis  such  as  the  infusion,  5  j  to  3  iv  (4  to  15  c.c), 
the  tincture,  Vf[v  to  xxx  (0.31  to  1.85  c.c),  or  the  powder,  gr.  j  (0.065 
gm.),  three  times  daily.  The  possibility  of  nausea  following  the 
use  of  digitalis,  especially  the  tincture,  should  be  remembered.  The 
dose  of  the  drug  is  best  guided  by  the  results  it  produces.  When 
for  any  reason  digitalis  is  not  applicable,  strophanthus,  strychnine, 
caffeine,  and  sparteine  may  be  given.  The  venous  engorgement 
and  dropsy  may  be  relieved  by  the  administration  of  small  doses  of 
mercury  and  saline  purgatives.  The  combination  of  calomel, 
digitalis,  and  squill,  of  each  gr.  j  (0.065  g^^^Oj  is  especially  valuable 
in  this  connection.  Venesection  (up  to  10  ounces)  is  often  of  use. 
When  the  dropsy  is  extreme,  tapping  or  multiple  incisions  may  be 
required.  The  extreme  and  distressing  shortness  of  breath  is  best 
relieved  by  morphine,  gr.  3^  (0.0165  gm.),  and  inhalations  of  oxygen. 
The  various  coal-tar  hypnotics  may  be  employed  but  are  less  efficient. 
When  the  cardiac  rhythm  is  disturbed  from  any  cause,  tincture  of 
belladonna,  TUv  to  xv  (0.31  to  0.92  c.c),  a  belladonna  plaster  over 
the  precordium,  or  nitroglycerin,  gr.  >foo  (0.00065  gi^-)>  should  be 
employed  in  addition  to  other  treatment.  Sudden  failure  of  the 
heart  requires  the  prompt  administration  of  diffusible  stimulants 
such  as  aromatic  spirit  of  ammonia,  whiskey,  nitroglycerin,  ether, 
etc  Ammonia  and  nitrite  of  amyl  should  be  inhaled  while  the 
other  remedies  should  be  given  hypodermically. 


HYPERTROPHY    OF    THE    HEART  417 

In  all  cases  in  which  the  general  health  fails  and  weakness  and 
emaciation  present  themselves,  resort  should  be  had  to  tonics  such 
as  iron,  quinine,  and  arsenic  in  addition  to  the  other  measures. 

DISEASES  OF  THE  MYOCARDIUM 

HYPERTROPHY  OF  THE  HEART 

Definition. — An  overgrowth  or  increase  in  the  muscular  tissue 
which  forms  the  walls  of  the  heart,  characterized  by  forcible  impulse, 
over-fullness  of  the  arteries,  diminished  blood  in  the  veins,  and 
accelerated  circulation. 

Causes. — It  is  most  frequently  caused  by  obstruction  to  the  out- 
flow of  blood  such  as  results  from  valvular  disease  of  the  heart, 
emphysema,  Bright's  disease,  and  arteriosclerosis,  but  it  may  also 
be  due  to  excessive  functional  activity,  such  as  produced  by  prolonged 
muscular  exertion,  exophthalmic  goitre,  the  long-continued  use  of 
large  amounts  of  tea,  coffee,  and  tobacco,  and  attempts  to  overcome 
pericardial  adhesions. 

Varieties. — I.  Simple  hypertrophy,  or  a  simple  increase  in  the 
thickness  of  the  cardiac  walls;  II.  Eccentric  hypertrophy,  increase  in 
the  cardiac  walls  and  dilatation  of  the  cavities,  causing  a  dilated 
hypertrophy;  III.  Concentric  hypertrophy,  increase  in  the  cardiac 
walls  with  decrease  of  the  cavities,  a  very  rare  form. 

Pathological  Anatomy. — Hypertrophy  of  the  heart  is  usually 
limited  to  the  left  side,  the  ventricles  being  more  commonly  involved 
than  the  auricles,  the  latter  dilating.  The  shape  of  the  heart  is 
altered  by  hypertrophy;  if  the  right  ventricle,  the  heart  is  widened 
transversely  and  the  apex  blunted;  if  the  left  ventricle,  the  heart  is 
elongated  and,  as  a  rule,  the  cavity  is  dilated;  if  both  ventricles  are 
hypertrophied,  the  heart  has  a  globular  shape.  From  increase  in 
weight  the  heart  may  fall  back  during  the  recumbent  position, 
thereby  lessening  the  area  of  cardiac  dullness,  but  during  the  sitting 
or  upright  posture  it  sinks  lower  in  the  chest  and  to  the  left,  causing 
more  or  less  prominence  of  the  abdomen.  The  increase  in  the  size 
of  the  organ  is  a  true  increase  or  hypertrophy  of  the  muscular  tissue, 
and  not  a  hyperplasia.  The  tissue  is  firmer  and  the  color  brighter  and 
fresher  than  when  the  size  of  the  organ  is  normal.  The  cor  hovinum 
of  the  old  writers  is  an  enormous  hypertrophy  of  the  heart  with  dila- 
tation of  its  cavities. 

27 


41 8  HYPERTROPHY   OF   THE   HEART 

Symptoms. — These  depend  upon  the  amount  of  hypertrophy; 
if  it  is  only  sufficient  to  compensate  for  valvular  defects  or  other  cir- 
culatory disturbances  there  will  be  no  symptoms.  When  the  enlarge- 
ment is  disproportionate  to  the  obstruction,  it  is  manifested  by 
increased  and  forcible  cardiac  action,  precordial  discomfort,  headache, 
dizziness,  ringing  in  the  ears,  flushes  or  flashes  of  light,  dyspnea  on 
exertion,  congestion  of  the  face  and  eyes,  dry  cough,  epistaxis,  and 
restless  nights,  with  more  or  less  jerking  of  the  limbs.  The  arteries 
become  full  and  the  pulse  is  firm  and  bounding.  The  carotids  and 
superficial  arteries  pulsate  markedly,  the  patient  frequently  com- 
plaining of  throbbing  sensations.  A  sphygmographic  tracing  shows 
the  line  of  ascent  vertical  and  abrupt,  but  the  apex  is  rounded,  and 
the  line  of  descent  is  oblique,  unless  there  is  more  or  less  insufficiency 
of  the  valves. 

Physical  Signs. — Inspection  reveals  fullness  or  prominence  of 
the  precordium  with  a  distinct  impulse. 

Palpation  detects  the  impulse  one  or  two  intercostal  spaces  lower 
down  and  to  the  left.  It  is  stronger  and  more  or  less  diffused — 
the  heaving  impulse. 

Percussion  determines  an  increase  in  the  area  of  cardiac  dullness 
vertically  and  transversely  on  the  left  side  of  the  sternum,  unless 
the  right  ventricle  is  also  hypertrophied,  when  the  cardiac  dullness 
is  increased  to  the  right  of  the  sternum. 

Auscultation  in  simple  hypertrophy  without  any  valvular  changes, 
detects  a  loud  first  sound  of  a  somewhat  metallic  quality,  the  second 
sound  being  strongly  accentuated.  In  the  presence  of  valvular 
disease  the  characteristic  murmurs  are  heard  in  addition. 

Sequels. — Cerebral  hemorrhage,  miliary  cerebral  aneurysms, 
cardiac  dilatation,  and  fatty  degeneration  may  be  mentioned  as  the 
most  common  sequels. 

Diagnosis. — The  history,  course,  symptoms,  and  physical  signs 
are  distinctive  and  when  carefully  considered  should  prevent  error 
in  diagnosis. 

Prognosis. — When  it  is  the  result  of  valvular  disease,  the  hyper- 
trophy is  said  to  be  compensatory.  If  the  result  of  Bright's  disease, 
emphysema  of  the  lung,  or  if  occurring  late  in  life,  or  associated  with 
atheromatous  degeneration  of  the  vessels,  the  prognosis  is  unfavor- 
able. When  it  is  the  result  of  functional  overacting  in  the  strong 
and  robust,  a  further  enlargement  can  often  be  prevented  by  active 
and  persistent  treatment. 


DILATATION   OF    THE   HEART  419 

Treatment. — When  the  hypertrophy  is  excessive,  the  indications 
are  to  remove  the  cause  if  possible  and  to  lessen  the  force  and  number 
of  the  cardiac  pulsations. 

The  habits  of  the  patient  should  be  corrected;  all  laborious  or 
active  exertion  should  be  restricted  and  the  recumbent  posture 
should  be  assumed  several  hours  during  the  day,  if  possible.  The 
diet  should  be  regulated,  and  all  forms  of  stimulants  such  as  liquors, 
tobacco,  tea,  and  coffee  should  be  interdicted.  Cases  of  cardiac 
hypertrophy  associated  with  Bright 's  disease  are  often  relieved  by 
digitalis.  In  rare  instances  cardiac  pain  follows  the  use  of  digitalis; 
in  such  cases,  citrated  caffeine  or  strophanthus  are  to  be  employed. 
When  the  hypertrophy  is  associated  with  anemia,  iron  should  be 
administered  in  addition  to  other  measures. 

The  force  and  frequency  of  the  cardiac  pulsations  are  best  con- 
trolled by  the  long-continued  use  of  tincture  of  aconite,  W[v  1 0.3  c.c), 
three  times  daily,  or  tincture  of  veratrum  viride,  TUx  (0.6  c.c), 
three  times  daily,  together  with  the  administration  of  saline  purga- 
tives, bromides,  and  nitrites  to  lessen  the  arterial  tension  and  to 
relieve  the  symptoms. 

DILATATION  OF  THE  HEART 

Definition. — An  increase  in  the  size  of  one  or  more  of  the  cavities 
of  the  heart,  characterized  by  feebleness  of  the  circulation,  terminat- 
ing in  venous  stasis,  cyanosis,  edema,  and  exhaustion. 

Causes. — It  is  usually  brought  about  by  chronic  valvular  heart 
disease,  emphysema,  chronic  bronchitis,  gout,  Bright's  disease, 
alcoholism,  or  syphilis,  but  may  be  due  to  overexertion  in  those  of 
feeble  resisting  powers,  such  as  youths  and  soldiers. 

Varieties. — I.  Simple  dilatation,  the  cavities  being  enlarged,  the 
walls  normal.  II.  Active  dilatation,  corresponding  to  eccentric 
hypertrophy;  the  cavities  being  enlarged  and  the  walls  increased  in 
thickness,  the  so-called  "dilated  hypertrophy."  III.  Passive  dilata- 
tion, the  cavities  being  enlarged  and  the  walls  thinned  or  stretched. 

Pathological  Anatomy. — The  right  side  of  the  heart  is  far  more 
frequently  involved  than  the  left  side.  The  shape  of  the  organ  is 
altered,  depending  on  the  part  affected.  The  weight  of  the  organ  is, 
as  a  rule,  increased,  as  hypertrophy  almost  always  accompanies  or 
precedes  dilatation.  The  muscular  tissue  is  generally  pale,  mottled, 
and  softened,  and  under  the  microscope  presents  evidences  of  degen- 


420  DILATATION    OF    THE    HEART 

eration.  The  orifices  also  participate,  and  especially  the  auriculo- 
ventricular  orifice,  resulting  in  the  valves  becoming  incompetent 
to  close  the  orifices,  and  this  latter  effect  is  increased  by  the  removal 
of  the  basis  of  the  papillary  muscles  a  greater  distance  from  the 
orifice,  in  consequence  of  the  distention  of  the  wall.  When  the 
auricles  dilate,  the  large  venous  trunks  opening  into  them^  unpro- 
tected by  valves,  commonly  participate  in  the  dilatation,  and  may 
become  greatly  enlarged.  The  passive  congestion  of  the  organs 
that  follows  the  enfeeblement  of  the  circulation  produces  changes  in 
their  structure. 

Symptoms. — The  manifestations  are  referable  to  the  enfeebled 
circulation  and  include  feeble  pulse,  headache  aggravated  by  the 
upright  position,  attacks  of  syncope,  cough,  dyspnea,  jaundice, 
dyspepsia,  constipation,  scanty,  often  albuminous  urine,  mental 
dullness,  vertigo,  often  relieved  by  a  copious  epistaxis,  and  finally 
dropsy  beginning  in  the  lower  extremities.  The  condition  terminates  . 
in  death  by  exhaustion.  Treatment  may  serve  to  temporarily 
relieve  any  of  the  symptoms  just  mentioned. 

Physical  Signs. — Inspection  detects  enlargement  and  distention 
of  the  superficial  veins  and  an  indistinct,  often  wavy  and  diffused, 
cardiac  impulse.  If  tricuspid  regurgitation  is  present,  jugular  pulsa- 
tion will  be  observed. 

Palpation  confirms  inspection;  the  impulse  is  feeble,  irregular, 
and  heaving. 

Percussion  serves  to  determine  extension  of  the  area  of  cardiac 
dullness  transversely  and  especially  toward  the  right  side. 

Auscultation  in  the  presence  of  valvular  lesions  reveals  character- 
istic murmurs.  If  there  are  no  valvular  lesions,  the  cardiac  sounds 
are  weaker  than  normal  and  the  first  sound  is  sharper  in  quality 
than  usual. 

Diagnosis. — Hypertrophy  of  the  heart  shows  increased  cardiac 
dullness  and  is  a  disease  of  powerful  cardiac  action,  while  dilatation 
is  an  affection  of  feeble  action  associated  with  dropsy. 

Pericardial  efusion  has  many  points  of  resemblance  to  cardiac 
dilatation,  but  it  begins  suddenly,  associated  with  some  acute  malady, 
and,  while  the  heart  sounds  are  indistinct  or  feeble  at  the  apex, 
they  both  have  their  normal  qualities  at  the  cardiac  base,  while 
dilatation  of  the  heart  has  a  chronic  history,  and  results  in  general 
venous  stasis,  the  cardiac  sounds  being  of  the  same  intensity  over  the 
entire  precordium. 


DILATATION   OF   THE   HEART  42 1 

Prognosis. — The  outlook  is  unfavorable.  Death  results  gradually 
from  exhaustion  or  suddenly  from  cardiac  paralysis  induced  by  some 
undue  excitement. 

Treatment. — Dilatation  of  the  heart  is  incurable.  The  symptoms 
may,  however,  be  temporarily  relieved  and  the  course  prolonged. 
In  all  cases  the  indications  are  to  improve  and  maintain  the  general 
nutrition  of  the  patient  and  to  control  and  steady  the  cardiac  action. 

The  first  indication  is  met  by  a  generous  diet,  moderate  exercise, 
and  the  administration  of  stomachics,  red  wine,  iron,  etc. 

The  second  indication  is  met  by  strict  observance  of  the  rules 
of  hygiene,  by  moderate  exercise,  and  by  the  administration  of  heart 
tonics  such  as  digitalis.  This  drug  may  be  used  in  the  form  of 
powder,  tincture,  or  infusion,  or  in  the  following  combination: 

I^.     Tincturas  nucis  vomicae. . .  .   f  5ss  15  c.c. 

Tincturas  digitalis f  5ss  15  c.c. 

M.  S. — Fifteen  drops  after  meals,  in  water. 

The  combination  of  tincture  of  strophanthus  with  digitalis  is  very 
beneficial.  Strychnine  sulphate,  gr.  ^^4  (0.0025  gin.),  three  times 
daily,  citrated  caffeine,  gr.  j  to  iij  (0.06  to  0.2  gm.),  three  times  daily, 
and  sparteine  sulphate,  gr.  >^  to  j  (0.0081  to  0.065  g"^.),  three  times 
daily,  are  also  valuable  heart  tonics  and  stimulants.  Morphine 
sulphate,  in  small  doses  hypodermically,  often  acts  like  magic  in 
restoring  the  circulation  (Bartholow)  especially  when  compensation 
is  failing,  and  dropsy  and  cyanosis  become  marked. 

The  following  pill  is  often  of  great  advantage: 

I^.     Ferri  reduct gr.  j  to  ij  0.065  to  0.13  gm. 

Quininae  sulph gr.  j  to  ij  o .  065  to  0.13  gm. 

Pulv.  digitalis gr.  j  0.065  gm. 

Morphinas  sulph. .......   gr.  ^^4  0.0025  gm. 

M.  S. — Three  times  a  day. 

An  excellent  combination  is  the  following: 

I^.     Tinct.  digitalis f  ojss.  6  c.c. 

Tinct.  cacti  grandifior f  §j  30  c.c. 

Caffeinae  citratse 5j  4  gm. 

Tinct.  card.  comp.  q.  s.  ad  fgiv     q.  s.  ad    120  c.c. 
M.  S. — Teaspoonful,  diluted,  three  or  four  times  daily. 

The  bowels,  skin,  and  kidneys  should  be  kept  in  action,  using,  if 


42  2  ACUTE   MYOCARDITIS 

needed,  purgatives,  diaphoretics,  and  diuretics.  The  following 
combination,  suggested  by  Dr.  J.  M.  Anders,  is  satisfactory  in  many 
instances : 

I^.     Caffeine  citratse 5j  4-0      gm. 

Strychninae  sulph gr.  M  0.022  gm. 

Sparteinae  sulph gr.  ij  0.13    gm. 

M.     Ft.  capsulae  No.  xij. 

S. — One  every  three  or  four  hours. 

Or  the  following  excellent  diiu"etic  pill: 

I^.     Pulv.  scillae gr.  xxx  2  . 0  gm. 

Pulv.  digitalis gr.  xxx  2.0  gm. 

Caff einas  citratae gr.  xxx  2  .  o  gm. 

Hydrarg.  chlor.  mitis gr.  v  0.3  gm. 

M.     Ft.  pilulae  No.  xxx. 

S. — One  three  or  four  times  daily. 

The  development  of  pulmonary  congestion  calls  for  the  use  of 
dry  cups,  digitalis,  caffeine,  atropine,  and  stimulants.  For  hepatic 
congestion,  blue  mass  and  podophyllin  are  indicated.  Cardiac 
asthma  may  be  relieved  to  a  great  extent  by  dry  cups,  morphine 
(hypodermically),  or  Hoffman's  anodyne.  The  dropsy  may  be 
lessened  by  dry  cups  over  the  kidneys,  digitalis,  potassium  acetate, 
scoparius,  preparations  of  juniper  berries,  and  compound  jalap 
powder.  If  the  dropsy  is  uninfluenced  by  these  means,  calomel, 
gr.  iij  (0.2  gm.),  guarded  by  powdered  opium,  gr.  ^{2  (0.00s  g^-)j 
three  times  daily,  should  be  employed. 

The  treatment  of  cardiac  dilatation  and  cardiac  failure  by  baths 
and  systematic  exercise  has  excited  much  interest  and  discussion 
recently,  with  the  result  of  its  indorsement  in  certain  cases.  Exercise 
is  employed  in  one  of  three  methods  or,  rarely,  a  combination  of 
these:  (i)  passive  exercise  and  massage  (Swedish  or  Ling  plan);  (2) 
movements  with  limited  resistance  (Schott  plan,  but  really  a  modifi- 
cation of  the  Swedish) ;  (3)  method  of  climbing  (Oertel) .  A  number  of 
American  and  English  clinicians  report  good  results  with  artificial 
Nauheim  baths.  This  system  of  cardiac  treatment  is  combined  with 
regulated  diet,  business  rest,  and  the  use  of  some  cardiac  tonics. 

ACUTE  MYOCARDITIS 

S3monyms. — Carditis;  abscess  of  the  heart. 

Definition. — An  inflammation  of  the  muscular  tissue  of  the  heart. 


CHRONIC   MYOCARDITIS  423 

characterized  by  pain,  feeble  circulation,  symptoms  of  blood-poison- 
ing, and  collapse. 

Causes. — It  nearly  always  arises  as  the  result  of  some  general 
septic  condition  such  as  pyemia,  septicemia,  typhoid  fever,  puerperal 
fever,  etc.,  but  it  may  be  due  to  extension  from  a  septic  pericarditis 
or  endocarditis. 

Pathological  Anatomy. — The  structural  changes  consist  in  dis- 
coloration and  softening  of  the  cardiac  substance  with  infiltration  of 
a  serosanguineous  fluid,  fibrinous  exudation,  and  pus,  leading  ulti- 
mately to  abscess  formation  in  the  myocardium.  The  affection 
terminates  in  either  cardiac  aneurysm  or  rupture  of  the  heart.  In 
the  event  of  recovery,  depressed  cicatrices  or  scars  will  be  found 
marking  the  sites  of  former  abscesses. 

Sjanptoms. — The  clinical  evidences  of  inflammation  of  the  cardiac 
muscles  are  very  vague.  If,  during  the  course  of  one  of  the  maladies 
mentioned,  there  are  developed  precordial  pain,  irregular  and  feeble 
cardiac  action,  cardiac  dyspnea,  pyrexia  of  a  low  type,  with  symptoms 
of  blood-poisoning  and  a  tendency  to  collapse,  or  the  symptoms_of 
the  so-called  typhoid  state,  myocarditis  may  be  suspected. 

Diagnosis. — The  diagnosis  is  seldom  made  before  death.  It 
may  be  presumed,  however,  if  in  the  course  of  septic  conditions, 
symptoms  of  heart  failure  occur. 

Prognosis. — The  course  of  acute  myocarditis  is  very  rapid,  death 
being  the  usual  termination  in  from  three  to  five  days. 

Treatment. — Cardiac  stimulants  should  be  employed  freely  in 
addition  to  the  other  remedial  measures  indicated  by  the  general 
sepsis. 

CHRONIC  MYOCARDITIS 

Synonyms. — Fibroid  heart ;  chronic  interstitial  myocarditis ;  fibrous 
myocarditis;   chronic   carditis;   cardiosclerosis. 

Definition. — A  slowly  developing  hyperplasia  of  the  interstitial 
connective  tissue  of  the  heart,  leading  to  induration  of  its  substance; 
characterized  by  shortness  of  breath  on  slight  exertion,  attacks  of 
tachycardia,  precordial  pain,  disordered  circulation,  and  vertigo. 
It  is  proper  to  state  that  many  cases  present  no  symptoms  whatever. 

Causes. — The  most  frequent  cause  is  sclerosis  of  the  coronary 
arteries,  leading  to  imperfect  blood  supply  to  the  cardiac  muscles. 
It  usually  occurs  in  the  aged  and  bears  a  direct  relation  to  the  condi- 
tion of  the  arteries  throughout  the  body.     Among  other  causes  may 


424  CHRONIC   MYOCARDITIS 

be  mentioned  diseases  of  the  kidneys,  alcoholism,  excessive  use  of 
tobacco,  syphilis,  pericarditis,  endocarditis,  and  acute  myocarditis. 
There  is,  undoubtedly,  often  an  inherited  predisposition  to  fibroid 
changes  in  the  vessels,  in  which  case  the  causes  named  would  act  as 
exciting  causes. 

Pathological  Anatomy. — The  heart  is  enlarged  and  dilated  and 
its  structural  changes  may  be  diffused  or  limited  to  the  v/alls  of  the 
left  ventricle,  the  papillary  muscles,  or  the  septum.  Valvular 
disease  may  be  present.  Atheroma  is  usually  present  in  one  or 
more  of  the  coronary  arteries  and  may  involve  the  aorta.  Sudden 
complete  closure  of  one  coronary  artery  in  the  course  of  these  morbid 
changes  is  usually  fatal. 

On  section  of  the  organ,  the  cardiac  wall  will  be  found  to  cut  with 
distinct  resistance,  due  to  an  overgrowth  of* the  interfibrillar  connect- 
ive tissue  and  the  development  of  new  fibrous  tissue.  When  due 
to  some  general  intoxication  such  as  accompanies  gout,  syphilis, 
alcoholism,  etc.,  these  changes  are  uniformly  distributed,  but  if 
due  to  embolism,  thrombosis,  or  other  conditions  including  one  or 
more  coronary  vessels  there  will  be  localized  anemic  infarction  and 
sclerosis.  On  microscopic  examination,  the  muscle  bundles  will  be 
found  degenerated  and  replaced  by  fibrous  tissue.  In  cases  due  to 
syphilis,  the  terminal  branches  of  the  coronary  arteries  are  narrowed 
and  sclerotic  to  the  point  of  obliteration.  The  inelastic  fibrous 
tissue  in  the  heart  is  often  insufficient  in  resisting  the  intracardial 
pressure  and  gives  way,  resulting  in  aneurysm  of  the  heart.  This 
is  particularly  liable  to  occur  in  localized  cardiosclerosis. 

Symptoms. — The  great  majority  of  patients  having  chronic 
myocarditis  present  no  symptoms  until  an  extra  cardiac  effort  is 
demanded.  An  early  symptom  is  breathlessness  on  slight  exertion, 
with  either  cardiac  palpitation  or  a  feeble,  irregular  pulse.  Vertigo 
is  frequent  and  distressing,  increased  by  indigestion  and  constipation. 
Anginal  attacks  (cardiac  pain)  or  sensations  of  constriction  or  pres- 
sure over  the  precordium  are  frequent,  often  following  some  exertion 
or  an  attack  of  indigestion.  The  pulse  rate  is  often  decreased  in 
frequency  in  cases  which  present  no  other  symptom,  A  frequent 
symptom  is  syncope,  coming  without  warning  or  after  sudden  exer- 
tion, the  result  of  sudden  failure  of  the  cerebral  circulation.  Among 
other  periodical  symptoms  are  cardiac  asthma,  pseudo-apoplectic 
attacks,  and  hepatic,  gastric,  and  nephritic  disorders.  x\s  the  fibroid 
changes   progress,   there   develop   progressive   weakness,    dyspnea, 


CHRONIC   MYOCARDITIS  425 

insomnia,  disordered  digestion,  and  cerebral  weakness,  often  showing 
itself  as  mania,  delusional  attacks,  or  dementia. 

Physical  Signs. — Inspection  and  palpation  recognize  a  feeble 
impulse  which  at  times  is  scarcely  appreciable. 

Percussion  detects  enlargement  of  the  area  of  cardiac  dullness  due 
to  the  dilated  hypertrophy  of  the  heart. 

Auscultation  shows  the  first  sound  of  the  heart  to  be  valvular  in 
quality,  the  booming  or  muscular  quality  having  disappeared. 
Murmurs  are  frequent  and  are  due  to  valvular  disease.  A  very 
characteristic  feature  is  irregularity  in  the  rhythm  and  force  of  the 
heart,  a  forcible  contraction  alternating  with  a  weak  contraction. 
Eventually  both  sounds  become  weak  and  feeble. 

Diagnosis. — The  points  of  value  in  arriving  at  a  diagnosis  are: 
a  careful  study  of  the  first  sound  of  the  heart  at  the  apex,  the  charac- 
ter of  murmurs  if  present,  the  conditions  of  the  arteries,  the  dyspnea, 
the  feeble,  irregular  pulse  in  patients  past  fifty  years  of  age,  and  the 
occurrence  of  anginal  attacks  after  exertion  or  mental  worry. 

Prognosis. — This  is  controlled  by  the  habits  of  the  patient.  The 
disease  is  incurable,  but  life  may  be  feirly  comfortable  for  many 
years  if  care  be  exercised.  It  should  be  remembered,  however,  that 
chronic  myocarditis  is  one  of  the  most  common  causes  of  heart 
failure  and  subsequent  death,  in  the  course  of  acute  pneumonia, 
typhoid  fever,  etc.,  and  after  overexertion  of  any  kind. 

Treatment. — No  remedy  can  remove  the  fibroid  change.  The 
indications  are  to  promote  the  patient's  nutrition,  hold  in  check  the 
progress  of  the  fibrosis,  and  meet  or  prevent  the  symptoms  as  they 
arise.  The  patient's  general  condition  requires  the  administration 
of  iron,  arsenic,'  and  the  hypophosphites.  Constipation  should  be 
avoided  by  the  use  of  aloes,  cascara,  or  other  mild  laxative.  Mental 
strain  and  physical  exertion  should  be  carefully  guarded  against  and 
tobacco  and  malt  liquors  should  be  interdicted.  The  diet  must  be 
plain  with  but  little  tea  or  coffee.  In  the  elderly,  a  small  amount  of 
good  whiskey  once  or  twice  daily  is  valuable.  The  Nauheim  treat- 
ment may  be  of  great  benefit  and  is  worthy  of  a  trial. 

Relief  of  the  symptoms  is  usually  obtained  by  measures  directed 
toward  supporting  the  heart.  For  breathlessness,  spirit  of  glonoin, 
spirit  of  nitrous  ether,  and  aromatic  spirit  of  ammonia  are  especially 
indicated.  Cardiac  palpitation  may  be  relieved  by  potassium  bro- 
mide, lithium  bromide,  and  aromatic  spirit  of  ammonia.  Weakness 
of  the  heart  requires  the  administration  of  strychnine  sulphate,  gr. 


426  FATTY   HEART 

^4  (0.0025  gm.),  three  times  daily;  tincture  of  digitalis,  TUx  to  xx 
(0.6  to  1.2  CO.),  three  times  daily; or  citrated  caffeine,  gr.  iij  (0.2  gm.), 
three  times  daily.  The  recumbent  position  should  be  assumed,  and 
gastrointestinal  disturbances  should  receive  prompt  treatment.  For 
the  anginal  attacks  hypodermic  injections  of  morphine  sulphate,  gr. 
}i  to  }i  (0.008  to  0.016  gm.),  should  be  given,  repeated  as  needed. 
When  syncopal  attacks  occur,  the  patient  should  be  placed  in  bed 
and  a  mustard  plaster  applied  to  the  precordium;  stimulants,  espe- 
cially nitroglycerin,  should  be  administered,  preferably  by  hypoder- 
mic injection.  The  following  is  an  excellent  combination  for  the 
relief  of  dyspnea,  vertigo,  and  chest  pains: 

I^.     Lithii  bromidi. 5vss  '  22  gm. 

Spiritus  glonoini TUxvj  i  c.c. 

Liq.  potassii  citratis 

q.  s.  ad  f  Bviij  ad     240  c.c. 

M.  S. — Tablespoonful  four  times  daily,  diluted. 

FATTY  HEART 

Synonyms. — Fatty  degeneration  of  the  heart;  chronic  myocarditis 

Definition. — A  change  in  the  muscular  fibers  of  the  heart,  in  which 
the  transverse  striee  are  replaced  by  granules  and  globules  of  fat, 
characterized  by  feeble  cardiac  action,  venous  stasis,  and  dyspnea. 

Causes. — The  most  important  factors  in  the  production  of  this 
condition  are  impaired  nutrition  in  the  elderly,  prolonged  anemia, 
chronic  gout,  alcoholism,  phosphorus  poisoning,  cancer,  tuberculosis, 
and  disease  of  the  coronary  arteries. 

Pathological  Anatomy. — Fatty  degeneration  should  be  distin- 
guished from  fatty  infiltration;  in  the  latter,  the  adipose  tissue  is 
deposited  on  the  organ  and  between  its  muscular  fibers.  This 
condition  is  to  some  extent  normal  and  accompanies  general  obesity. 

Fatty  degeneration  affects  the  individual  muscle  fibers;  the  changes 
being  within  and  not  between  the  fibers.  The  fatty  metamorphosis 
may  affect  the  whole  organ,  or  the  entire  ventricular  walls,  or  may 
be  limited  to  portions  of  them.  If  the  degeneration  be  marked,  the 
color  is  yellowish,  the  tissues  soft  and  easily  torn,^and  with  a  greasy 
feeling,  oil  being  yielded  on  pressure. 

The  microscopical  changes  are  characteristic.  The  stris  of  the 
muscle  are  rendered  indistinct  by  fat  and  oil  globules,  gradually 


FATTY   HEART  427 

becoming  more  and  more  obscured,  and  finally  disappearing  alto- 
gether, the  fibers  being  replaced  by  fat  granules. 

S3miptoms. — The  manifestations  of  fatty  degeneration  are  weak- 
ness of  the  heart,  anemia  of  the  various  organs,  and  venous  stasis. 
The  cardiac  action  is  slow,  feeble,  and  irregular,  and  the  pulse  is 
compressible.  Precordial  distress  is  present,  often  aggravated  by 
attacks  of  angina  pectoris.  Dyspnea,  increased  on  exertion,  is  also 
a  symptom.  Anemia  of  the  brain  induces  vertigo,  swooning,  and 
pseudo-epileptic  attacks,  especially  marked  on  suddenly  rising  from 
a  recumbent  posture.  Anemia  of  the  lungs  gives  rise  to  a  dry  hacking 
cough.  Anemia  of  the  gastrointestinal  tract  produces  dyspepsia 
and  constipation.  Renal  anemia  is  followed  by  scanty,  often  al- 
buminous urine  and  dropsy  beginning  in  the  lower  extremities. 
Weakness  and  pallor  are  common  symptoms. 

A  formidable  symptom,  causing  much  inconvenience  as  well  as 
alarm  to  the  patient,  is  that  which  he  will  term  his  constant  "sighing" 
the  Cheyne-Stokes  breathing — "A  pause  in  the  breathing,  a  complete 
suspension  of  the  respiratory  acts  for  a  period  of  time  (during  which 
breathing  might  occur  several  times  in  the  normal  manner),  then  the 
resumption  of  respiration  very  feebly  and  slowly,  and  a  gradual  and 
progressive  increase  in  the  number  and  depth  of  respirations  until 
the  maximum  is  reached,  and  then  again  a  gradual  and  progressive 
diminution  in  the  same  order,  in  the  number  and  depth  of  the  respira- 
tions, until  another  pause  occurs" — the  "oscillating  respiration." 

Concomitant  symptoms  are  atheromatous  changes  in  the  vessels, 
and  the  arcus  senilis. 

Physical  Signs. — Palpation  detects  a  weak  and  irregular  cardiac 
impulse. 

Percussion  determines  no  change  in  the  area  of  cardiac  dullness 
unless  cardiac  hypertrophy  is  present. 

Auscultation  reveals  a  feeble,  toneless,  almost  inaudible  first 
sound.  The  second  sound  is  normal.  Murmurs  are  not  present 
unless  there  are  coincident  valvular  lesions. 

Diagnosis. — Feeble  cardiac  sounds,  with  slow  pulse,  attacks  of 
cardiac  asthma  or  Cheyne-Stokes  breathing,  and  evidences  of  arcus 
senilis,  make  the  diagnosis  very  certain.  The  question  of  fibroid 
heart  must  always  be  considered. 

Prognosis. — The  outlook  is  unfavorable.  Life  may  be  prolonged 
by  appropriate  treatment  but  death  is  liable  to  occur  at  any  time  from 
cardiac  paralysis,  rupture  of  the  heart,  or  exhaustion. 


428  PALPITATION    OF    THE    HEART 

Treatment. — There  is  no  treatment  capable  of  restoring  the 
degenerated  muscle  fibers  to  their  normal  condition.  Various  means 
may  be  employed,  however,  for  lessening  the  severity  of  the  symp- 
toms. Mental  and  physical  exertion  should  be  avoided.  The 
diet  should  be  generous  and  consist  of  easily  digested  substances. 
Moderate  exercise  should  be  prescribed.  Stimulants  such  as  iron, 
quinine,  strychnine,  cod-liver  oil,  and  hypophosphites  should  be 
administered  over  an  indefinite  period  to  strengthen  and  maintain 
the  body  tone.  All  the  secretions  should  be  kept  active  to  relieve 
the  crippled  heart  from  any  unnecessary  strain.  The  recumbent 
posture  should  be  assumed  for  several  hours  each  day.  The  Nau- 
heim  treatment  is  applicable.  The  heart's  action  is  best  sustained 
by  strychnine  sulphate,  gr.  }i8  to  3^2  (0.0015  to  0.002  gm.),  three 
or  four  times  daily,  but  caffeine,  sparteine,  and  nux  vomica  may  also 
be  employed.  Digitalis  is  contraindicated  in  advanced  cases.  For 
syncopal  attacks,  nitroglycerin,  spirit  of  nitrous  ether,  aromatic 
spirit  of  ammonia,  and  hypodermic  injections  of  ether,  camphor,  or 
whiskey  are  indicated. 

FUNCTIONAL  AFFECTIONS  OF  THE  HEART 

PALPITATION  OF  THE  HEART 

Synonym. — Irritable  heart. 

Definition. — A  functional  disturbance  of  the  heart;  characterized 
by  increasing  frequency  of  its  movements  and  more  or  less  irregularity 
of  the  rhythm,  with  a  strong  tendency  toward  hypertrophy. 

Causes. — Among  the  more  important  causes  may  be  mentioned 
female  sex,  puberty,  menstrual  disorders,  anemia,  emotion,  mental 
anxiet}'-,  hysteria,  overexertion  following  acute  or  chronic  disease, 
'' heart-strain"  (DaCosta),  dyspepsia,  long-continued  use  of  tea, 
coffee,  tobacco,  and  alcohol  in  large  quantities,  and  excessive  venery. 

S3miptoms. — Usually  palpitation  of  the  heart  has  a  sudden  onset 
after  some  one  of  the  causes  mentioned,  with  precordial  oppression 
or  pain;  rapid,  tumultuous  beating,  the  impulse  being  visible  through 
the  patient's  clothing;  dyspnea,  anxiety,  and  a  sense  of  choking  or 
fullness  in  the  throat,  the  recumbent  position  being  impossible; 
vertigo,  faintness,  flashes  of  light,  the  pulse  full  and  strong  or  feeble, 
and  the  face  flushed  or  pale,  the  patient  having  a  feeling  of  anxiety 
with  a  sense  of  impending  danger  and  a  fear  of  sudden  death.     These 


TACHYCARDIA  429 

attacks  are  paroxysmal,  lasting  from  a  few  moments  to  several  hours 
or  a  day,  the  patient  often  voiding  a  large  quantity  of  limijid  urine 
after  the  paroxysm  has  subsided,  when  there  is  a  strong  tendency  to 
sleep. 

Diagnosis. — Palpitation  or  irritability  of  the  heart  is  differen- 
tiated- from  the  various  forms  of  cardiac  disease  by  the  absence  of 
all  the  physical  signs  mentioned  as  occurring  in  those  conditions. 

Prognosis. — If  early  and  properly  treated,  favorable. 

Treatment. — The  first'  point  in  the  treatment  is  to  remove 
the  cause;  the  next,  to  prevent  the  recurrence  of  the  attacks  of 
palpitation. 

The  majority  of  cases  do  well  after  a  few  doses  of  either  compound 
spirit  of  ether  (Hoffmann's  anodyne)  or  aromatic  spirit  of  ammonia, 
or  a  combination  of  digitalis  and  belladonna.  Permanent  relief  is 
often  afforded  by  a  combination  of  potassium  bromide  and  veratrum 
viride.  Trional,  gr.  x  to  xv  (0.6  to  i  gm.),  three  times  daily,  is  often 
useful.  If  the  patient  be  anemic,  excellent  results  follow  the  pro- 
longed use  of  the  elixir  of  iron,  quinine,  and  strychnine.  Locally, 
belladonna  plaster  to  the  precordium  affords  relief.  It  may  be  nec- 
essary to  direct  attention  to  sexual  hygiene.  The  acute  attack  is 
often  wonderfully  benefited  by  ice  over  the  precordium. 

TACHYCARDIA 

Synonyms. — Rapid  heart;  quick  heart;  paroxysmal  rapid  heart. 

Definition. — Paroxysmal  rapid  cardiac  action  with  or  without 
subjective  symptoms. 

Causes. — The  direct  cause  is  somewhat  obscure.  The  condition 
may  be  found  associated  with  one  of  the  crises  of  cerebral  or  spinal 
disease,  the  menopause,  neuritis  of  the  pneumogastric  nerve,  chronic 
myocarditis,  neurasthenia,  chronic  gastritis,  the  excessive  use  of 
tobacco,  petit  mal,  pyrexia,  lesions  of  the  base  of  the  brain,  etc. 

Pathology. — The  affection  has  no  structural  lesions  peculiar  to 
itself.  There  may  be  paralysis  of  the  inhibitory  fibers  of  the  vagus, 
a  direct  irritation  of  the  accelerators  of  the  sympathetic,  or  reflex 
irritation  from  some  lesion  in  the  cardiac  wall  or  elsewhere  in  the 
body. 

Symptoms. — The  paroxysm  is  sudden  in  its  onset,  with  or  without 
''warnings" — if  these  latter  occur,  they  are  in  the  shape  of  vertigo, 
ringing  in  the  ears,  and  a  sense  of  impending  danger.     The  cardiac 


43  O  BRADYCARDIA 

action  is  increased  to  150,  175,  200,  rarely  250  beats  per  minute. 
The  pulse  is  small,  weak,  easily  compressible,  and  often  irregular, 
with  carotid  pulsation  (which  indicates  emptiness  and  low  tension 
of  the  artery,  as  in  aortic  regurgitation).  The  respiration  is  slightly 
increased;  rarely  there  is  dyspnea.  The  surface  is  at  first  pale,  but 
soon  becomes  flushed.  The  expression  is  anxious  and  denotes  suffer- 
ing. There  is  a  feeling  of  precordial  constriction,  with  more  or  less 
smothering.     Rarely,  subjective  symptoms  are  absent. 

The  duration  is  from  a  few  minutes  to  hours  or  days.  The  attack 
usually  ceases  during  sleep,  but  the  rapidity  of  the  pulse  may  continue 
during  the  disturbed  sleep. 

Auscultation  detects  a  clear  and  ringing  first  sound,  the  strong  and 
booming  character  being  absent.  The  second  sound  is  weak  and 
lacks  the  valvular  quality  of  the  normal.  A  murmur  is  often  heard 
at  the  apex. 

Diagnosis. — The  principal  points  in  distinguishing  tachycardia 
from  other  cardiac  affections  are  the  paroxysmal  character,  and  the 
great  increase  in  the  pulse  rate  and  cardiac  action  of  which  the 
patient  may  or  may  not  be  conscious. 

Prognosis. — When  occurring  as  a  pure  neurosis  or  as  the  result 
of  some  cause  that  permits  of  easy  removal,  the  prognosis  is  good. 
It  is  often,  however,  an  unfavorable  symptom  of  some  central 
lesion.  When  it  develops  in  persons  suffering  from  chronic  myocardi- 
tis or  atheroma  of  the  vessels,  it  is  liable  to  terminate  suddenly  in  death. 

Treatment. — As  in  other  affections  involving  the  cardiac  functions, 
rest  in  bed  is  of  great  importance  in  the  treatment.  The  application 
of  ice  to  the  precordium,  together  with  the  hypodermic  injection 
of  morphine  sulphate,  gr.  3^  (o.oii  gm.),  and  atropine  sulphate,  gr. 
3^00  (0.00065  gi^-))  s-re  of  great  benefit  during  the  paroxysm.  Occa- 
sionally, the  administration  of  a  few  large  doses  of  digitalis  brings 
about  the  restoration  of  cardiac  equilibrium.  Sedatives  such  as 
tincture  of  belladonna,  the  bromides,  camphor,  trional,  etc.,  are  at 
times  valuable  in  arresting  the  attacks.  During  the  intervals 
between  the  paroxysms,  the  habits  should  be  regulated  and  harmful 
substances,  such  as  alcohol,  tobacco,  tea,  and  coffee  should  be 
interdicted. 

BRADYCARDIA 

Synonym. — Brachycardia. 

Definition. — A  paroxysmal  or  permanent  slowness  in  the  cardiac 


ARRHYTHMIA  43 1 

action.  It  is  agreed  that  bradycardia  begins  when  the  pulse  is 
reduced  to  at  least  40  beats  per  mintite. 

Causes. — It  is  often  associated  with  organic  nervous  diseases  and 
is  a  symptom  of  such  cardiac  diseases  as  fibroid  and  fatty  heart  and 
atheroma  of  the  coronary  arteries  (and  see  Heart-block). 

The  condition  frequently  occurs  during  convalescence  from  infec- 
tious diseases,  such  as  diphtheria,  pneumonia,  typhoid  fever,  erysip- 
elas, and  rheumatism;  uremia,  lead-poisoning,  anemia,  and  chronic 
alcoholism  are  often  causes.  According  to  Balfour,  "Many,  if 
not  most,  of  the  sufferers  from  bradycardia  are  epileptics." 

Symptoms. — The  slow  action  of  the  heart,  varying  from  40  beats 
to  as  few  as  8  beats  per  minute,  is  the  most  prominent  manifestation. 
The  pulse  is  weak,  small,  and  slow.  The  first  sound  of  the  heart 
is  soft  and  feeble  and  often  the  second  sound  is  inaudible.  As  a 
result  of  the  slow  cardiac  action  there  are  noises  in  the  ears,  vertigo, 
syncopal  attacks,  and  rarely  convulsions.  Premonitory  signs  may 
or  may  not  be  present. 

Prognosis.^ — The  outlook  depends  entirely  upon  the  cause.  When 
due  to  grave  organic  disease,  sudden  death  is  not  an  uncommon 
termination. 

Treatment. — As  long  as  the  slo¥/  cardiac  pulsations  are  sufficient 
to  supply  the  requirements  of  the  economy,  medication  is  not  needed; 
when,  however,  the  reverse  obtains,  rest  in  the  recumbent  position, 
heat  to  the  precordium,  and  the  use  of  such  remedies  as  atropine 
sulphate,  citrated  caffeine,  strychnine  sulphate,  spirit  of  glonoin, 
and  aromatic  spirit  of  ammonia  are  indicated.  Often  the  emergency 
is  so  great  as. to  call  for  the  hypodermic  use  of  the  selected  drug. 

Digitalis  is  contra-indicated.  Between  the  paroxysms,  such  reme- 
dies as  improve  the  general  health  and  prevent  the  progress  of  the 
central  or  exciting  cause  are  required. 

ARRHYTHMIA 

Sjmonyms. — Arrhythmia  cordis;  irregularity  of  the  pulse. 

Definition. — ^A  lack  of  cardiac  rhythm,  or  irregularity  in  the 
cardiac  pulsations.     It  is  a  symptom  rather  than  a  disease. 

Causes. — Valvular  diseases;  myocardial  diseases;  cardiac  dilated 
hypertrophy;  atheroma  of  coronary  arteries  and  aorta;  excessive 
use  of  tobacco,  tea,  or  coffee;  flatulent  dyspepsia;  neurasthenia, 
hysteria,  and  melancholia. 


432  HEART-BLOCK 

Symptoms. — An  irregularity  in  cardiac  action,  either  in  the  rhythm 
or  the  regularity  of  the  force  of  the  beats,  or  an  intermission  in  the 
cardiac  contractions.  Symptoms  referable  to  the  underlying  cause 
are  also  present. 

Diagnosis. — An  examination  of  the  pulse,  ausculation  of  the  heart, 
and  the  use  of  the  sphygmograph  determine  the  arrhj^hmia. 

Prognosis. — This  depends  upon  the  cause;  in  functional  cases 
it  is  favorable,  in  organic  cases  unfavorable. 

Treatment. — In  purely  functional  conditions  rest  of  mind  and 
body  with  regulation  of  the  diet,  attention  to  the  secretions,  and  the 
administration  of  the  bromides  are  of  great  value.  In  other  cases, 
strychnine  or  digitalis  in  addition  to  treatment  directed  toward  the 
underlying  cause  is  indicated. 

HEART-BLOCK 

This  is  a  form  of  cardiac  arrhythmia  characterized  by  partial  or 
complete  dissociation  of  the  auricular  and  ventricular  systole.  The 
relation  between  auricular  and  ventricular  beats  may  be  2  to  i,  3  to  i, 
or  4  to  I ;  or  the  two  cavities  may  pulsate  quite  independently  of  each 
other.  Clinically  the  condition,  which  is  known  as  Stokes-Adams 
disease  or  syndrome,  manifests  itself  in  bradycardia  and  periodic 
syncopal  attacks,  with  or  without  convulsions.  Secondary  symptoms 
are  disturbances  of  digestion,  nausea  and  vomiting,  or  both,  and  of 
respiration,  dyspnea  on  exertion  and,  sometimes,  Cheyne-Stokes 
breathing.  The  pulse  rate  falls  as  low  as  40  or  30  to  the  minute, 
and  is  not  influenced  by  active  movements  or  change  of  position; 
simultaneous  jugular  and  radial  tracings  show  partial  or  complete 
dissociation  of  the  auricular  and  ventricular  systole.  The  syncopal 
attacks  are  probably  due  to  cerebral  anemia;  sometimes  the  attacks 
are  apoplectiform  or  epileptiform  (cerebral  congestion),  and  an 
epigastric  aura  occasionally  occurs. 

The  cause  of  heart-block  is  believed  to  be  a  destructive  lesion  of  the 
bundle  of  His,  also  known  as  GaskelVs  bridge,  a  bundle  of  muscular 
tissue,  extending  from  the  right  side  of  the  interauricular  septum  to 
the  interventricular  septum,  immediately  below  the  membranous 
portion.  It  is  the  pathway  by  which  the  impulse  initiating  the 
contraction  of  the  heart  is  conveyed  from  the  auricle  to  the  ventricle. 
Among  the  pathological  findings  in  cases  of  heart-block  may  be 
mentioned;  gumma;  syphilitic  ulcer  or  scar;  arteriosclerosis   with 


ANGINA   PECTORIS  433 

calcareous  nodnle  compressing  the  bundle;  lesions  of  the  coronary- 
arteries;  anemic  necrosis;  abscess  and  ulcer  of  pyogenic  origin;  tumors 
and  infarcts.  Treatment  should  be  directed  toward  the  associated 
conditions.  In  partial  heart-block  atropine  is  said  to  be  of  service. 
In  cases  of  syphilitic  origin  antisyphilitic  treatment  should  be  insti- 
tuted; and  in  doubtful  cases  a  Wassermann  test  should  be  made. 

ANGINA  PECTORIS 

S5aionyms. — Neuralgia   of   the   heart;    stenocardia;   breast-pang. 

Definition. — Paroxysms  in  which  there  occur  sharp  cardiac  pains, 
extending  usually  into  the  left  shoulder  and  down  the  left  arm, 
accompanied  by  a  feeling  of  constriction  of  the  thorax  and  a  strong 
fear  of  impending  death. 

Causes. — The  direct  cause  of  the  affection  is  insufficient  nutrition 
of  the  heart.  This  deficiency  may  be  brought  about  by  disease  or 
obstruction  of  the  coronary  arteries,  diseased  conditions  of  the  aortic 
valve,  pressure  of  an  adjacent  tumor,  excessive  dilatation  or  enlarge- 
ment of  the  heart,  adhesive  pericarditis,  habitual  use  of  tobacco,  etc. 
The  tendency  may  be  inherited.  Syphilis  and  hysteria  may  exert 
an  influence  in  its  production.  According  to  Trousseau  it  may  be 
considered  as  a  form  of  masked  epilepsy  or  it  may  alternate  with 
true  epileptic  attacks.  Allbutt  believes  it  to  be  due  to  an  acute 
aortitis.  Male  adults  after  forty  years  of  age  are  most  often  affected 
and  the  attacks  are  precipitated  by  overexertion,  great  mental 
excitement,  or  acute  indigestion. 

Pathology. — The  most  constant  structural  changes  are  sclerosis, 
atheroma,  and  obliteration  of  the  coronary  arteries.  Such  changes 
may  be  present  without  angina  and,  on  the  other  hand,  anginoid 
attacks  may  occur  independent  of  structural  alterations.  Functional 
disturbances  of  the  cardiac  plexuses  are  responsible  for  the  symptoms. 

Symptoms. — The  chief  symptom  is  intense  agonizing  pain  which 
begins  in  the  region  of  the  heart  and  extends  to  the  neck  and  down 
the  left  arm.  Shortness  of  breath,  and  precordial  oppression  are 
present.  The  chest  is  fixed  and  the  heart's  action  is  weak  and  feeble. 
The  face  is  pale  green  or  ashen  gray,  the  expression  is  anxious,  and 
there  is  a  fearful  sense  of  impending  death.  The  body  and  face  are 
covered  with  drops  of  cold  sweat.  The  pain  usually  lasts  but  a  few 
seconds  or  minutes.  Extreme  prostration  follows  the  attack  unless 
it  is  terminated  meanwhile  by  death.  The  end  of  the  paroxysm  is 
28 


434 


ANGINA   PECTORIS 


marked  by  cessation  of  the  pain  and  precordial  distress,  and  by 
vomiting,  or  excessive  flow  of  urine.  The  first  attack  may  end  in 
death  or  there  may  be  a  recurrence  at  varying  periods,  sometimes 
extending  over  years. 

The  unpleasant  sensations  of  these  patients  during  an  attack, 
and  the  nervous  disorder  associated  with  it,  slowly  bring  about  a 
mental  change.  They  are  depressed  and  gloomy,  sometimes  suicidal, 
and  often  develop  epilepsy. 

Attack  of  angina  in  nervous  women  and  children,  the  hysterical 
or  pseudo-anginal  attacks,  comxC  on  gradually  with  distention  of  the 
abdomen,  eructations  of  gases,  excessive  restlessness,  flushed  face, 
irritable  pulse,  diffused  precordial  pain,  and  the  general  phenomena 
of  hysteria. 

In  a  few  cases  the  pain  is  absent,  but  all  other  symptoms  are 
present — the  ^'angina  sine  dolore^'  of  Gairdner.  Balfour  claims  that 
pain  is  not  an  essential  part  of  the  disease. 

Diganosis. — The  points  to  be  remembered  are  that  the  attacks 
are  always  paroxysmal,  with  long  or  short  intervals,  the  patient 
having  a  sense  of  coldness,  and  frequently  a  cold  sweat,  the  heart's 
action  being  not  increased,  the  chest  fixed,  and  the  breathing  slow. 

Intercostal  neuralgia  and  gastralgia  may  be  confused  with  this 
affection,  but  the  history  and  concomitant  symptoms  of  the  former 
conditions  will  aid  greatly  in  making  a  diagnosis.  These  affections 
lack  the  characteristic  paroxysms  observed  in  true  angina  pectoris. 

Pseudo-angina  is  well  differentiated  in  Huchard's  table : 


True  angina 

Pseudo-angina 

Most  common  past  middle  life 

At  every  age  from  six  years. 

Most  common  in  men 

Mnst.  nnrnmon  in  fprnalps. 

Attacks — rarely  nocturnal  or  periodical 

Not  associated  with  other  symptoms 

Agonizing  pain  and  sense  of  constriction 

Pain  of  short  duration 

Often  periodical  and  nocturnal. 
Associated  with  nervous  symptoms. 
Pain  less  severe — distention  more  than 

constriction. 
Pain  lasts  one  or  two  hours. 

Lesions  of  arterial  sclerosis .  .  . 

Neuralgic  affection. 
Never  fatal. 

Prognosis  grave;  often  fatal 

Prognosis. — The  outlook  in  true  angina  pectoris  is  unfavorable. 
Seventy-five  per  cent,  recover  from  the  first  attack  but  the  affection 
ultimately  terminates  fatally.  In  pseudo-angina  the  prognosis  is 
always  favorable. 

Treatment. — The  Attack:  Prompt  relief  follows  the  immediate  in- 


ARTERIOSCLEROSIS  435 

halation  of  amyl  nitrite,  lUiij  to  v  (0.2  to  0.3  c.c),  or  chloroform,  or 
the  hypodermic  injection  of  morphine  sulphate,  gr.  ^  (0.016  gm.), 
combined  with  atropine  sulphate,  gr.  Koo  (0.00065  g"^-),  or  nitro- 
glycerin, gr.  Hoo  to  }io  (0.00065  to  0.0013  gn^-)-  In  many  cases,  the 
use  of  nitroglycerin,  gr.  Koo  (0.00065  gin.),  three  times  daily,  over  an 
extended  period,  lessens  not  only  the  frequency  but  also  the  severity 
of  the  paroxysm.  Sparteine  sulphate,  gr.  }i  (0.016  gm.),  three  times 
daily,  is  also  highly  recommended.  The  application  of  a  mustard 
plaster  or  other  form  of  counterirritation  to  the  precordium  is  pro- 
ductive of  considerable  benefit. 

The  Interval:  Attempts  should  be  made  to  remove  the  exciting 
causes  or  to  diminish  their  influence.  Great  care  should  be  exercised 
in  the  diet  that  flatulency  and  constipation  do  not  occur.  Mental 
excitement  and  physical  exertion  should  be  avoided.  When  struc- 
tural changes  are  suspected,  potassium  iodide,  gr.  x  to  xx  (0.6  to  1.3 
gm.),  three  times  daily,,  should  be  administered.  The  nitrites,  and 
nitroglycerin  should  be  employed  as  they  lessen  materially  the  fre- 
quency and  severity  of  the  paroxysms.  Tonics  such  as  iron,  arsenic, 
strychnine,  phosphorus,  etc.,  are  of  value  in  that  they  increase  the 
resistance  of  the  body  and  improve  its  general  tone.  Strophanthus 
and  strychnine  are  indicated  when  the  heart  is  weak.  Trousseau 
advises  the  long-continued  administration  of  small  doses  of  bella- 
donna. Quain  employs  the  constant  current,  applying  the  positive 
pole  over  the  sternum  and  the  negative  pole  over  the  lower  vertebrae. 
The  Nauheim  treatment,  particularly  the  hot  baths,  may  be  of  bene- 
fit.    The  cold  baths  are  positively  harmful  in  this  condition. 

Pseudo-angina  requires  the  treatment  prescribed  for  hysteria  in 
general. 

DISEASES  OF  THE  ARTERIES 

ARTERIOSCLEROSIS 

Synonyms. — Atheroma ;  arteriocapillary  fibrosis ;  endarteritis  chron- 
ica deformans. 

Definition. — A  chronic  degenerative  and  inflammatory  disease  of 
the  vascular  system,  resulting  in  an  overgrowth  of  the  connective 
tissues  of  the  arteries,  followed  by  calcareous  deposits.  The  changes 
may  extend  to  the  capillaries  and  veins.  As  a  result  of  the  impair- 
ment of  the  arterial  circulation,  there  occur  fibroid  degenerations  in 


436  ARTERIOSCLEROSIS 

other  organs,  resulting  in  loss  of  elasticity  in  the  walls  of  the  vessels, 
increase  of  arterial  tension,  narrowing  of  the  caliber  of  smaller  arter- 
ies, and  impairment  of  the  nutrition  of  the  organs  supplied. 

Causes. — The  principal  etiological  factors  are  senility,  heredity, 
male  sex,  alcoholism,  syphilis,  lead-poisoning,  diabetes,  malaria, 
gout,  rheumatism,  lithemia,  Bright's  disease,  exposure,  and  excesses 
of  various  kinds.  The  condition  of  the  arteriocapillary  system  may 
be  taken  as  an  index  of  an  individual's  age.  The  main  factors  are 
''time,  tension,  and  toxins." 

Pathological  Anatomy. — The  atheromatous  changes  are  most 
frequent  in  the  aorta.  Rokitansky  gives  the  relative  order  in  which 
atheromatous  degenerations  occur  as  follows:  aorta,  splenic,  femoral, 
iliac,  coronary  arteries  of  the  heart,  arteries  of  the  brain,  uterine, 
subclavian,  brachial,  ulnar,  and  radial  arteries. 

The  internal  surface  of  the  affected  vessels  is  irregularly  thickened 
with  gelatinous  and  translucent,  dense  and  fibrous,  or  calcareous 
deposits.  If  the  calcification  is  extensive,  the  vessel  is  changed  into 
a  hard,  stiff  tube.  Often  the  surface  of  the  thickening  or  deposit  is 
destroyed,  presenting  the  so-called  "atheromatous  ulcers,"  which 
may  be  covered  with  masses  of  thrombi. 

The  above  conditions  are  the  result  of  inflammatory  change  in  the 
intima  of  the  affected  vessel  which  appears  three  or  four  times  as 
thick  as  normal,  due  to  the  swelling  of  its  elements,  the  new  growth 
of  connective  tis?ue,  and  the  deposit  of  round  cells.  Fatty  degenera- 
tion of  the  inflammatory  products  is  the  common  sequence. 

The  result  of  the  changes  in  the  arteries  is  a  loss  of  elasticity,  thus 
hindering  the  propulsion  of  the  blood  current  and  raising  the  arterial 
tension,  ultimately  leading  to  hypertrophy  of  the  left  ventricle. 
These  changes  finally  involve  the  coronary  arteries  and  lead  to  altera- 
tions in  the  myocardium.  The  nutrition  of  various  other  organs  is 
likewise  impaired  when  the  intima  of  their  respective  arteries  is  in- 
volved in  the  degenerative  process. 

Symptoms. — These  are  not  always  apparent  and  vary  with  the 
arteries  involved  and  their  distribution.  When  the  process  is  general, 
the  peripheral  arteries  have  a  hard  bony  feel,  not  unlike  whip-cord. 
The  increased  resistance  of  the  arterial  system  induces  increased 
cardiac  activity  and  consequent  hypertrophy. 

Attacks  of  vertigo,  pseudo-apoplectic  attacks,  or  spells  of  uncon- 
sciousness in  the  aged  or  those  having  superficial  hardened  arteries, 
are  generally  due  to  changes  in  the  cerebral  vessels.     Evidences  of 


ANEURYSM   OF    THE    AORTA  437 

myocarditis  and  angina  pectoris  point  to  atheroma  of  the  aorta  and 
coronary  arteries.  Renal  arteriosclerosis  manifests  itself  as  chronic 
interstitial  nephritis.  Gangrene  of  the  extremities  in  the  old — senile 
gangrene — points  to  atheroma  or  thrombi,  the  result  of  the 
fibrosis. 

Physical  Signs. — Palpation  reveals  a  forcible  cardiac  impulse  in 
the  early  stages.  The  superficial  arteries  are  hard  and  those  at  the 
wrists  feel  like  a  string  of  beads  pulsating. 

Percussion  shows  increased  precordial  dullness  especially  over  the 
left  ventricle. 

Auscultation  in  the  early  stage  detects  prolongation  of  the  first 
sound  with  the  accentuation  of  the  second  sound  over  the  aortic 
cartilage.  As  the  heart  dilates  and  the  walls  become  diseased,  the 
sound  becomes  feeble  and  often  irregular  and  intermittent. 

Sequels. — As  consequences  of  this  condition  of  the  arterial  system 
may  be  mentioned  cerebral  hemorrhage,  thrombosis,  embolism,  or 
aneurysm,  myocarditis,  angina  pectoris,  chronic  interstitial  nephritis, 
gangrene,  aneurysm,  etc. 

Prognosis. — The  structural  changes  may  be  prevented  or  retarded 
but  cannot  be  removed. 

Treatment. — The  habits,  hygiene,  mode  of  life,  diet,  etc.,  should 
be  most  carefully  regulated.  When  the  cause  or  causes  are  detected 
they  should  be  promptly  removed.  The  secretions  should  be  kept 
free  at  all  times.  Constipation  should  be  avoided  as  it  serves  to 
embarrass  the  functional  activity  of  the  liver  and  kidneys.  Alcohol 
should  be  interdicted.  Moderate  exercise  is  of  benefit.  Potassium 
iodide  and  nitroglycerin  should  be  administered  in  small  doses 
indefinitely.     Overexertion  of  any  kind  should  be  avoided. 

ANEURYSM  OF  THE  AORTA 

Varieties. — I.  Aneurysm  of  the  arch  of  the  aorta.  II.  Aneurysm 
of  the  thoracic  aorta.     III.  Aneurysm  of  the  abdominal  aorta. 

The  arch  of  the  aorta  is  divided  into  three  parts — the  ascending, 
the  transverse,  and  the  descending. 

The  ascending  portion  is  2  inches  in  length,  arising  from  the  left 
ventricle,  on  a  level  with  the  lower  border  of  the  left  third  costal 
cartilage,  behind  the  left  edge  of  the  sternum.  It  ascends  obliquely 
upward  to  the  right  to  the  upper  border  of  the  right  second  costo- 
sternal   articulation.     The    transverse    portion    commences   at   the 


438      ANEURYSM  OF  THE  ARCH  OP  THE  AORTA 

Upper  border  of  the  right  second  sternal  articulation,  and,  arching 
to  the  left  and  forward,  passes  in  front  of  the  trachea  and  esophagus 
to  the  left  of  the  third  dorsal  vertebra.  The  descending  portion 
extends  downward  to  the  left  side  of  the  fourth  dorsal  vertebra. 

The  thoracic  aorta  extends  from  the  left  lower  border  of  the  fourth 
dorsal  vertebra,  and  ends  in  front  of  the  body  of  the  twelfth  dorsal 
vertebra,  at  the  aortic  opening  in  the  diaphragm. 

The  abdominal  aorta  begins  at  the  aortic  opening  in  the  diaphragm, 
descends  a  little  to  the  left  side  of  the  vertebral  column,  and  ter- 
minates over  the  body  of  the  fourth  lumbar  vertebra,  where  it  divides 
into  the  two  iliac  arteries. 

Definition. —  A  circumscribed  dilatation  of  some  portion  of  the 
aorta,  the  result  of  disease  of  the  vessel  wall  weakening  its  resistance 
to  the  blood  pressure. 

Causes. — Conditions  that  induce  arteriosclerosis  are  the  chief 
causes.  Exertion  is  an  exciting  cause.  Aneurysms  occur  in  early 
middle  life  rather  than  in  old  age,  when  the  force  of  the  heart  has 
decreased.     They  are  more  common  in  men  than  in  women. 

Pathological  Anatomy. — All  aneurysms  may  be  divided  into 
two  classes,  dissecting  and  circumscribed.  Dissecting  aneurysms 
occur  in  the  aged  and  result  from  fatty  changes  in  the  internal  and 
middle  coats.  The  intima  usually  ruptures  allowing  the  blood 
to  dissect  its  way  between  the  coats  of  the  vessel.  Circumscribed 
aneurysm  is  most  common  in  middle-aged  men  and  can  usually  be 
ascribed  to  syphilis.  It  consists  of  a  circumscribed  dilatation  of  the 
affected  vessel.  It  may  be  fusiform,  sacculated,  or  cylindrical  in 
shape.  A  true  aneurysm  is  one  in  which  the  dilatation  is  confined 
to  the  vessel  wall ;  a  false  aneurysm  is  one  in  which  the  vessel  wall  has 
ruptured  and  the  extravasated  blood  has  become  encapsulated  by 
the  adjacent  connective  tissue. 

ANEURYSM  OF  THE  ARCH  OF  THE  AORTA 

Etiology. — In  addition  to  the  general  causes,  given  alone,  there 
are  many  reasons  given  why  aneurysm  should  be  so  common  in  the 
arch  of  the  aorta,  viz.:  The  arch  of  the  aorta  is  very  curved,  the  first 
part  of  the  arch  has  but  little  support,  the  force  of  the  blood  current 
tends  to  bulge  the  aorta  locally,  in  this  part  large  branches  are  given 
ojff  in  a  very  small  area;  cardiac  pressure  shows  greater  variations 
here  than  in  parts  further  away. 


ANEURYSM  OF  THE  ARCH  OF  THE  AORTA      439 

Symptoms. — This  variety  of  aneurysm  is  the  most  common. 
The  onset  is  usually  gradual,  with  evidences  of  arteriosclerosis  and 
failing  health.  Pain,  which  may  be  paroxysmal  or  continuous,  is 
a  constant  symptom.  Dyspnea  is  also  common  and  may  be  constant 
with  acute  exacerbations,  or  may  be  remittent.  Occasionally, 
dysphagia  occurs.  A  slight  brassy  or  ringing  cough  from  pressure 
on  the  recurrent  laryngeal  nerve,  with  more  or  less  alterations  in  the 
voice,  may  be  present.  The  pupils  are  dilated  or  contracted,  or  are 
irregular  in  some  cases,  due  to  pressure  on  the  sympathetic  nerve. 
There  are  disorders  of  the  circulation,  a  gradual  loss  of  flesh,  and  a 
careworn  expression  of  the  face. 

Physical  Signs. — Inspection  is  negative  until  the  tumor  becomes 
large  when  circumscribed  bulging  and  abnormal  pulsation  may  be 
noticed. 

Palpation  detects  expansile  pulsation  (Corrigan's  sign)  which  is 
characteristic.  Tenderness  may  be  present  over  the  aneurysm. 
A  thrill  may  be  detected.  Diastolic  shock  due  to  the  recoil  of 
the  blood  in  the  aneurysm  on  the  closed  aortic  valve  may  also  be 
recognized. 

Tracheal  tugging  is  often  present  and  is  diagnostic.  To  obtain 
it,  the  patient  should  be  placed  in  the  erect  position,  with  his  mouth 
closed  and  chin  elevated  to  the  greatest  extent.  The  cricoid  cartilage 
should  then  be  grasped  between  the  fingers  and  thumb  and  gentle 
traction  upward  should  be  made.  The  pulsations  of  the  dilated 
aorta  or  aneurysm,  if  any  exist,  will  then  be  distinctly  felt,  in  most 
cases  transmitted  through  the  trachea  to  the  hand.  Aneurysm  of 
the  arch  also  gives  rise  to  alteration  in  the  radial  pulse.  When  the 
aneurysm  is  situated  at  the  transverse  portion  of  the  arch,  the  left 
radial  pulse  and  the  left  carotid  pulse  are  smaller  and  weaker  than 
those  on  the  right  side. 

Percussion  yields  an  abnormal  area  of  dullness  with  increased 
resistance. 

Auscultation  serves  to  elicit  a  murmur  or  bruit  over  the  tumor 
synchronous  with  the  first  sound  of  the  heart.  It  is  louder  than 
the  systole,  lower  in  pitch,  and  of  a  blowing  character.  When  the 
aortic  valves  are  intact,  the  second  aortic  sound  will  be  markedly 
accentuated. 

Diagnosis. — The  presence  of  a  tumor,  as  shown  by  the  abnormal 
area  of  dullness,  with  expansile  pulsation  and  a  bruit  in  the  region 
occupied  by  the  aortic  arch,  is  diagnostic.     The  :\:-ray  will  serve  to 


440 


ANEURYSM  OF  THE  ARCH  OF  THE  AORTA 


define  its  exact  situation  and  outlines.  The  signs  and  symptoms  will 
vary  according  to  the  part  of  the  arch  involved.  This  is  well  shown 
in  the  following  table  from  Wheeler  and  Jack. 


Ascending 


Transverse 


Descending 


Physical  signs.. 


Pulsation,  often  ex- 
pansile, in  second 
and  third  interspaces. 

On  palpation  systolic 
thrill  and  diastolic 
shock  to  right  of 
sternum. 

Dullness  to  right  of 
sternum,  above  car- 
diac area. 

Rough  systolic  mur- 
mur, loud  clanging 
second  sound.  May 
have  diastolic  mur- 
mur from  implica- 
tion of  aortic  valve. 


Parts  liable  to 
pressure  and 
results  of  pres- 
sure. 


Vena    cava    superior; 

dilated        superficial 

veins,  edema  of  head 

and  neck. 
Innominate        artery; 

weakness      of      right 

radial  pulse. 

Heart;  downward 

displacement  of 

apex. 

Ribs  to  right  of  ster- 
num; pain. 


Right  bronchus;  de- 
fective respiration 
on  right  side. 


Right  recurrent  laryn- 
geal (rarely) ;  paraly- 
sis of  right  vocal 
cord. 


Pulsation  in  episternal 
notch.  I 

Systolic  thrill  in  epi- 
sternal notch. 


Dullness     over     man- 
ubrium sterni. 

Murmur  more  distinct 
over  manubrium. 

Diastolic        murmur 
rare. 


Left  innominate  vein; 
edema  of  left  side  of 
head  and  neck. 

Any  branch  of  the 
arch;  weakness  of 
right  or  left  radial 
pulse. 


Manubrium 
pain. 


sterni; 


Pulsation,    if   any,    to 
left  of  spine. 

Absent. 


No  dullness  anteriorly, 
sometimes  dull  to 
left  of  spine. 

Murmur  may  be 
absent;  when  pres- 
ent systolic,  to  left 
of  spine. 


Trachea  or  left 
bronchus;  paroxys- 
mal dyspnea,  al- 
tered cough  defect- 
ive respiration  on 
left  side. 

Left  recurrent  laryn- 
geal; paralysis  of 
left  vocal  cord. 

Sympathetic;  dilata- 
tion or  contraction 
of  pupil,  usually  left. 


Esophagus; 
phagia. 


dys- 


Spinal  column,  and 
ultimately  cord; 

dorsal  pain,  after- 
ward paraplegia. 

Left  bronchus;  defect- 
ive respiration  on 
left  side. 


Left  recurrent  laryn- 
geal; paralysis  of 
left  vocal  cord. 

Left  sympathetic 

(often) ;  dilatation  or 
contraction  of  left 
pupil. 

Esophagus;  dys- 

phagia. 

Thoracic  duct;  rapid 
emaciation  some- 
times chylous  as- 
cites. 


Rupture 
occur. 


may    Externally 

Into  pericardium. 


Into  right  pleura. .  .  . 
Into  right  bronchus. 
Into  superior  cava. 


Into  trachea Into  left  bronchus. 

Into     one     or     other    Into  left  pleura. 

pleura.   _  _  1 

Into  left  innominate. .  i  Into  esophagus. 


ANEURYSM    OF    THE    ABDOMINAL   AORTA  44 1 

ANEURYSM  OF  THE  THORACIC  AORTA 

Symptoms. — The  most  constant  symptom  is  deep-seated  thoracic 
pain,  constant  or  paroxysmal.  Dysphagia  is  a  frequent  condition. 
There  is  seldom  dyspnea,  and  alteration  of  voice  and  pupils  does  not 
occur.     Death  may  occur  suddenly. 

Physical  signs  are  seldom  distinctive  and  the  diagnosis  is  rarely 
made  during  life. 

ANEURYSM  OF  THE  ABDOMINAL  AORTA 

Symptoms. — The  most  constant  symptom  is  pain  situated  in  some 
area  corresponding  to  the  aneurysm,  or  widely  diffused  over  the 
abdomen.  Gastrointestinal  symptoms  appear  and  the  general  health 
fails.  The  pressure  of  the  tumor  induces  retardation  of  the  femoral 
pulse.  Other  pressure  symptoms  depend  on  the  location  of  the 
aneurysm.     In  most  cases,  it  is  situated  near  the  celiac  axis. 

The  physical  signs  reveal  abnormal  dullness,  and  the  presence  of  a 
tumor  with  expansile  pulsation  and  a  bruit  to  the  left  of  the  median 
line  of  the  abdomen. 

Diagnosis. — Pulsating  abdominal  aorta  may  be  distinguished  from 
abdominal  aneurysm  by  its  occurrence  in  paroxysms,  in  nervous 
women  and  effeminate  men,  and  by  the  absence  of  a  tumor,  expansile 
pulsation,  and  pressure  symptoms. 

Abdominal  tumors  resting  on  the  aorta  may  transmit  its  pulsation. 
The  assumption  of  the  knee-chest  posture  causes  the  tumor  to  fall 
away  and  the  pulsation  is  lost. 

Prognosis  of  Aortic  Aneurysm. — Unfavorable.  The  duration  of 
life  after  the  development  of  the  aneurysm  is  from  one  to  four  years. 
The  termination  may  be  sudden  from  rupture  and  hemorrhage,  or 
gradual  from  exhaustion. 

Treatment. — The  object  of  the  treatment  is  to  promote  coagulation 
of  the  blood  within  the  sac  and  to  bring  about  contraction  of  the 
tumor,  at  the  same  time  being  careful  to  avoid  violent  rupture. 

The  so-called  Tufnell's  method  is  the  most  successful  for  these  pur- 
poses, its  aim  being  to  diminish  the  force  and  rapidity  of  the  circula- 
tion, and,  if  possible,  to  increase  the  fibrinous  deposit.  Its  essential 
element  is  absolute  rest  of  mind  and  body,  and  a  restricted  diet;  the 
patient  is  kept  absolutely  in  bed  day  and  night  for  at  least  three 
months,  and  placed  on  the  following  diet:  Breakfast — 2  ounces  of 


442  PHYSICAL  DIAGNOSIS 

bread  with  butter  and  2  ounces  of  milk;  dinner — 2  or  3  ounces  of  bread, 
same  amount  of  meat,  and  2  to  4  ounces  of  milk  or  claret  wine;  supper 
■ — 2  ounces  of  bread  with  butter  and  2  ounces  of  milk.  At  the  same 
time  potassium  iodide  is  administered  in  increasing  doses  to  the 
physiological  limit. 

Galvanopuncture  is  said  to  do  good  in  some  cases;  two  needles 
inserted  into  the  aneurysm  are  connected  with  the  poles  of  a  galvanic 
battery,  and  a  weak  current  is  passed  through  the  tumor.  Various 
surgical  procedures  have  been  employed,  from  time  to  time,  but  the 
success  following  them  is  doubtful. 

The  severe  pain  indicates  the  use  of  morphine  and  the  local  appli- 
cation of  an  ice-bag.  Cyanosis  and  dyspnea  will  be  relieved  to  some 
extent  by  venesection. 

DISEASES  OF  THE  RESPIRATORY  SYSTEM 

PHYSICAL  DIAGNOSIS 

Physical  diagnosis  is  the  art  of  discriminating  disease  by  means 
of  the  eye,  the  ear,  and  the  touch. 

The  signs  thus  ascertained  are  connected  with  changes  or  altera- 
tions in  the  form,  density,  or  condition  of  the  structures  within,  and 
are  known  as  physical  signs. 

"Physical  signs  are,  then,  the  exponents  of  physical  conditions, 
and  of  nothing  more"  (DaCosta). 

The  methods  employed  in  the  physical  exploration  of  the  chest, 
are:  I,  Inspection;  II,  Palpation;  III,  Mensuration;  IV,  Percussion; 
V,  Auscultation ;  VI,  Succussion. 

Chest  Divisions. — For  the  purpose  of  physical  exploration,  the 
chest  is  mapped  off  into  regions  or  divisions,  as  follows: 

ANTERIORLY 

1.  Supra-clavicular,  lying  above  the  upper  edge  of  the  clavicle, 
usually  about  an  inch  in  extent.  It  contains  the  apex  of  each  lung, 
with  portions  of  the  subclavian  and  carotid  arteries  and  the  sub- 
clavian and  jugular  veins. 

2.  Clavicular,  corresponding  to  the  inner  two-thirds  of  the  clavicle. 

3.  Infra-clavicular,  from  the  clavicle  to  the  lower  border  of  the 
third  rib,  and  from  the  edge  of  the  sternum  to  a  line  drawn  vertically 


PHYSICAL    DIAGNOSIS  443 

downward  from  the  junction  of  the  middle  and  outer  third  of  the 
clavicle.  This  region  contains  the  upper  lobe  of  the  lung  and  main 
bronchi;  on  the  right  side  the  superior  vena  cava  and  part  of  the 
aortic  arch;  and  on  the  left  side  a  portion  of  the  pulmonary  artery. 

4.  Mammary,  between  the  third  and  sixth  riVjs.  In  the  center 
of  this  region  between  the  fourth  and  fifth  ribs  is  placed  the  nipple. 
On  the  right  side  this  region  contains  the  right  lung,  part  of  the 
diaphragm,  a  portion  of  the  right  auricle  and  right  ventricle;  on  the 
left  side,  the  lung  and  a  small  part  of  the  right  ventricle. 

5.  Infra-mammary ,  downward  from  the  sixth  rib  to  the  margin  of 
the  false  ribs.  On  the  right  side  it  contains  the  liver  and  a  small  por- 
tion of  the  lung  on  deep  inspiration;  on  the  left, side,  the  left  lobe  of 
the  liver,  stomach,  and  part  of  the  spleen. 

6.  The  upper  sternal  region  extends  from  the  suprasternal  notch  to 
the  junction  of  the  third  costal  cartilage  and  stfernum.  The  ascend- 
ing arch  of  the  aorta,  portions  of  the  superior  vena  cava,  the  innomi- 
nate veins,  subclavian  arteries,  esophagus,  and  trachea  are  found  in 
this  region. 

7.  The  lower  sternal  region  extends  downward  from  the  junction  of 
the  third  costal  cartilage  with  the  sternum,  and  contains  portions  of 
the  lung,  right  and  left  ventricles,  and  stomach. 

The  mammillary  line  or  nipple  line  extends  vertically  through  the 
nipple;  but  this  latter  is  far  too  variable  in  position  to  be  taken  as  a 
''fixed  point." 

The  parasternal  line  is  a  vertical  line  placed  midway  between  the 
border  of  the  sternum  and  the  mammillary  line. 

LATERALLY 

1.  Axillary,  that  portion  above  the  sixth  rib.  The  upper  lobes  of 
the  lung  and  the  main  bronchi  are  to  be  found  in  this  region. 

2.  Infra- axillary,  that  portion  below  the  sixth  rib.  On  the  right 
side,  it  contains  the  lung  and  liver;  on  the  left  side,  the  lung,  stomach, 
and  spleen. 

POSTERIORLY 

1.  Supra-scapular,  that  portion  above  the  scapula. 

2.  Scapular,  that  portion  covered  by  the  scapula.  It  contains  the 
greater  portion  of  the  lung. 


444 


PHYSICAL  DIAGNOSIS 


Fig.  53. — Anterior  View  of  the  Lungs,  Heart,  and  Abdominal  Organs  with 
Reference  to  their  Relation  to  the  Skeleton  and  the  Outline  of  the  Stomach. 
(Tyson's  Diagnosis.) 

I,  Larynx;  2,  thyroid  gland;  3,  trachea;  4,  right  lung  apex;  5,  upper  lobe,  6,  middle 
lobe,  7,  lower  lobe,  of  right  lung;  8,  upper,  9,  lower,  interlobular  boundary  of  the  right 
lung;  10,  apex,  11,  upper  lobe,  12,  lingual  process  of  the  left  lung;  13,  cardiac  boundary 
of  the  anterior  border  of  the  left  lung;  14,  portion  of  the  anterior  aspect  of  the  peri- 
cardium covered  bv  the  cardiac  pleura;  15,  portion  of  the  same  uncovered  by  diaphragm. 
Site  for  paracentesis;  16,  anterior  border  of  the  mediastinum;  17,  anterior  border  of  the 
left  mediastinum;  18,  upper  or  true  border  of  the  liver  partially  covered  by  lung;  19, 
right  lobe  of  the  liver;  20,  quadrate  lobe  of  the  liver;  21,  left  lobe  of  the  liver;  22,  gall- 
bladder; 23,  cardiac  end  of  the  stomach;  24,  stomach  cul-de-sac  partially  covered  by 
lung;  25,  pyloric  end  of  the  stomach;  26,  larger  curvature  of  the  stomach  (right  gastro- 
epiploic artery);  27,  transverse  colon;  28,  ascending  colon;  29,  descending  colon;  31. 
small  intestine.     (After  Luschka,  slightly  modified.) 


PHYSICAL   DIAGNOSIS  445 

3.  Inter-scapular,  that  portion  between  the  scapulae.  It  extends 
from  the  second  to  the  sixth  vertebra  and  contains  portions  of  the 
lungs,  bronchi,  esophagus,  and  descending  aorta. 


Fig.  54. — Posterior  View  of  the  Organs  of  the  Chest  and  Abdominal  Cavity 

{Tyson's  Diagnosis.) 

I,  Upper  lobe,  2,  lower  lobe  of  left  lung;  3,  interlobular  boundary  between  them; 
4,  upper  lobe  of  right  lung;  5,  lower  lobe  of  right  lung;  6,  middle  lobe  of  the  right  lung; 
7,  line  between  upper  and  middle  lobes  of  the  right  lung;  9,  stomach  demarked  by  a 
dark  line;  10,  spleen  in  its  relation  to  the  lung  in  expiration  with  the  kidney  showing 
behind  and  below  it;  11,  left  kidney;  12,  horizontal  upper  part  of  the  duodenum;  13. 
descending  portion  of  the  duodenum;  14,  horizontal  lower  part  of  the  duodenum; 
15,  duodeno-jejunal  flexure;  16,  liver;  20,  pancreas;  21,  first  dorsal  vertebra.  {After 
Luschka.) 

4.  Infra-scapular,  that  portion  below  the  angle  of  the  scapula  and 
above  the  twelfth  rib.  On  the  right  side,  it  contains  a  portion  of  the 
lung,  liver,  and  kidney;  on  the  left  side,  a  portion  of  the  lung  and  in- 
testine, spleen,  kidney,  and  descending  aorta. 


446 


PHYSICAL   DIAGNOSIS 


INSPECTION 

Inspection  signifies  "the  act  of  looking."  Views  of  the  chest  should 
be  taken  from  the  sides  and  behind  as  well  as  from  the  front,  for  which 
purpose  a  good  light  should  be  obtained,  and  the  patient  be  placed  in 
as  easy  and  comfortable  a  position  as  is  possible. 

Inspection  reveals  the  form,  size,  color,  and  movements  of  the  chest, 
as  well  as  the  condition  of  the  superficial  parts. 

Variations  in  Form.— The  phthis- 
ical chest  is  characterized  by  a  short 
anteroposterior  diameter  and  a  long 
vertical  diameter.  The  chest  is  flat, 
and  the  ribs  are  oblique.  The  supra- 
and  infra-clavicular  spaces  are  much 
depressed  and  an  acute  angle  is 
formed  at  the  lower  portion  by  the 
divergence  of  the  costal  margins  from 
the  sternum.  Posteriorly  the  scap- 
ulse  are  very  prominent. 

The  rachitic  chest  is  marked  by  flat- 
tening of  the  sides,  with  prominence  of 
the  sternum  {pigeon-breast).  Beading 
of  the  sternal  ends  of  the  ribs  {rachitic 
rosary)  and  circular  constriction  of 
the  chest  at  the  level  of  the  xiphoid  cartilage  {Harrison's  groove) 
are  often  present  in  "addition. 

The  emphysematous  chest  is  distinguished  by  being  abnormally 
round  and  short.  The  transverse  and  anteroposterior  diameters  may 
be  equal  in  some  cases.  It  is  also  known  as  the  "keg  or  barrel-shaped 
chest."  The  ribs  are  horizontal  and  the  costal  angle  is  obtuse  or 
obliterated. 

Sternal  depressions  are  usually  congenital,  but  may  be  acquired  as 
the  result  of  occupation,  as  in  the  case  of  shoemakers.    • 
Sternal  enlargements  are  generally  congenital. 

Localized  depressions  of  the  chest  may  result  from  pulmonary 
tuberculosis,  fibroid  lung,  or  adhesions  following  pleurisy  or  other 
pulmonic  conditions. 

Localized  or  one-sided  enlargements  may  be  caused  by  pleural 
effusion,  compensatory  emphysema,  tumors  of  the  abdomen  or  chest, 
pneumothorax,  hydrothorax,  hemothorax,  and  enlargement  of  the 
heart  (left  side). 


Fig.  55. — I,  J>Jormai  chest;  2, 
pigeon  breast;  i,  rickets;  4,  em- 
physema. (Gee;  modified.) 
{Greene's  Medical  Diagnosis.) 


PHYSICAL   DIAGNOSIS  447 

Expansion. — In  health  the  sides  of  the  chest  are  for  the  most  part 
symmetrical  in  form,  size,  color,  and  movements,  both  sides  rising 
equally  during  the  act  of  inspiration,  and  falling  equally  during  the 
act  of  expiration.  During  the  act^  of  inspiration  the  intercostal 
spaces  in  the  lower  two-thirds  of  the  chest  become  more  hollow,  as  do 
also  the  supra-clavicular  fossae. 

Inspiration  is  almost  entirely  the  result  of  muscular  action; 
expiration,  on  the  other  hand,  is  chiefly  due  to  the  elasticity  of  the 
lungs  and  chest-walls,  aided  somewhat  in  forced  respiration  by  mus- 
cular action.  The  movement  of  inspiration  by  inspection  is  of  longer 
duration  than  that  of  expiration,  and  the  pause  between  the  acts  but 
momentary. 

The  respiratory  movement  is  visible  over  the  whole  thorax,  although 
in  males  and  in  children  it  is  most  distinct  at  the  lower  portion 
{inferior  costal  breathing) ,  while  in  the  female  it  is  most  distinct  at  the 
upper  portion  of  the  chest  (superior  costal  breathing). 

The  abnormal  variations  in  expansion  of  the  chest  are  usually  uni- 
lateral. Diminished  unilateral  expansion  is  common  to  acute  pleu- 
risy, pulmonic  consolidation  from  any  cause,  collapse  of  the  lung  from 
bronchial  obstruction,  tumors,  and  abdominal  enlargements.  In- 
creased unilateral  expansion  occurs  in  compensatory  emphysema. 

PALPATION 

By  palpation  is  meant  the  application  of  the  palmar  surfaces  of  the 
hands  and  fingers  to  the  chest,  by  means  of  which  are  appreciated 
impressions,  that  are  capable  of  being  conveyed  by  the  sense  of  touch. 

The  objects  of  palpation  are: 

1.  To  give  more  accurate  information  of  what  is  revealed  by 
inspection. 

2.  To  locate  areas  of  tenderness,  the  density  and  condition  of 
tumors,  if  any  be  present;  the  state  of  the  chest  walls,  the  frequency 
of  the  breathing,  and  the  action  of  the  heart.  Tenderness  of  the 
chest  wall  may  be  produced  by  traumatism,  caries  and  fracture  of 
the  ribs,  intercostal  neuralgia,  pleurodynia,  and  pleurisy  (alone  or 
combined  with  other  lung  conditions  as  phthisis  and  pneumonia). 
Edema  of  the  chest  may  be  due  to  anasarca,  empyema,  or  pulnionary 
abscess. 

3.  To  determine  the  existence  and  character  of  the  various  kinds 
of  fremitus  (vibrations).     By  fremitus  is  understood  certain  tactile 


448  PHYSICAL  DIAGNOSIS 

impressions  or  vibrations  conveyed  to  the  surface  of  the  chest,  which 
are  classed  and  produced  as  follows: 

1.  Vocal  fremitus,  produced  by  the  act  of  speaking  or  crying. 

2.  Tussive  fremitus,  produced  by  the  act  of  coughing;  of  value 
especially  when  the  voice  is  very  weak. 

3.  Bronchial  fremitus,  produced  by  the  passage  of  air  through 
mucus,  blood,  or  pus,  in  the  bronchial  tubes,  during  the  act  of 
respiration, 

4.  Friction  fremitus,  produced  by  the  rubbing  together  of  the 
roughened  surfaces  of  the  pleura. 

When  the  normal  chest  vibrates  lightly,  it  is  termed  the  normal 
vocal  fremitus. 

The  vocal  fremitus  is  more  distinct  upon  the  right  side  toward 
the  apex. 

If  the  lung  be  consolidated  (denser),  the  vibration  is  greater  and 
more  easily  distinguished,  the  vocal  fremitus  is  increased.  As  exam- 
ples of  conditions  with  increased  vocal  fremitus  may  be  mentioned 
croupous  pneumonia,  phthisis,  and  bronchopneumonia. 

In  feeble  persons,  or  when  any  cause  interferes  with  the  trans-, 
mission  of  the  vibrations,  the  vocal  fremitus  is  diminished  or  absent. 
This  is  observed  in  pleural  effusions,  emphysema,  collapse  of  the 
lung,  tumors,  and  pulmonary  edema. 

MENSURATION 

Mensuration,  or  measurement  of  the  chest,  is  of  less  practical 
importance  than  the  other  methods  named,  and  hence  is  seldom 
performed.  The  only  measurement  likely  to  be  required  is  the  cir- 
cular or  circumferential,  in  different  parts  of  the  chest;  this  is  taken 
with  either  an  ordinary  graduated  tape-measure  or  a  double  tape- 
measure,  made  by  uniting  two  tapes  in  such  a  manner  that  they 
start  in  opposite  directions  from  the  same  point  at  the  mid-spinal 
line.  The  tapes  drawn  around  each  side  until  they  meet  at  the 
mid-sternal  line,  on  a  line  immediately  above  the  nipple,  or  on 
the  level  of  the  sixth  rib  near  its  attachment  to  the  cartilage — the 
sixth  costo-stemal  joint — the  patient  first  being  directed  to  effect 
a  complete  expiration,  the  number  of  inches  noted,  and  then  to  take 
a  deep  inspiration,  the  increase  in  inches  noted,  the  difference  between 
the  two  giving  a  rough  estimate  of  the  capacity  of  the  lungs. 

In  right-handed  persons  the  right  side  is  usually  )-^  to   %  inch 


PHYSICAL  DIAGNOSIS  449 

larger  than  the  left;  if  larger  than  this,  it  is  usually  the  result  of  some 
abnormal  condition. 

In  well-developed  men,  the  chest  measures  at  the  upper  part  about 
SS  to  36  inches  during  expiration,  and  is  increased  fully  3  inches  upon 
inspiration. 

PERCUSSION 

Percussion,  or  "the  act  of  striking,"  to  ascertain  the  composition 
of  structures,  affords  signs  and  information  of  great  value  in  diagnosis. 

There  are  two  methods  employed,  immediate  and  mediate. 

Immediate,  or  direct  percussion,  is  performed  by  striking  the 
thorax  directly  with  the  points  of  the  fingers  or  the  palmar  surface 
of  the  hand.  This  method  of  percussion  has  been  generally 
abandoned,  as  it  does  not  enable  the  physician  to  distinguish  with 
sufficient  accuracy  between  the  various  shades  of  difference  in  the 
pitch  or  quality  of  percussion  sounds. 

Mediate,  or  indirect  percussion,  may  be  practised  in  three  different 
ways: 

1.  With  the  finger  of  one  hand  interposed  between  the  body 
percussed  and  the  percussing  finger. 

2.  With  the  finger  acting  as  a  pleximeter  and  the  percussion 
hammer. 

3.  With  the  percussion  hammer  and  the  pleximeter. 

The  first  of  these  modes  affords  the  fnost  correct  and  ready  in- 
formation regarding  the  resistance  of  the  parts  percussed;  further, 
the  physician  has  his  fingers  with  him.  But  the  skilful  use  of  the 
fingers  is  more  difficult  to  acquire  than  that  of  the  pleximeter  and 
hammer;  and  if  the  examiner  has  acquired  sufficient  skill  in  its  per- 
formance, an  absolutely  accurate  result  may  be  obtained.  He 
who  is  skilled  in  digital  percussion  will  be  able  to  percuss  equally  well 
with  the  hammer,  the  inverse  of  which  does  not  always  hold  good." 
In  addition  to  being  proficient  in  technique,  it  is  necessary  to  possess 
a  sensitive  ear,  educated  to  distinguish  between  the  various  shades 
of  the  sounds. 

When  the  fingers  are  employed,  it  is  a  matter  of  choice  whether 
one  or  more  fingers  are  used  as  the  pleximeter.  Usually  the  last 
phalanx  of  the  first  or  second  fingers  of  the  left  hand  are  used,  the 
other  fingers  being  raised  from  the  chest,  so  as  not  to  interfere  with  the 
sound  vibrations;  they  should  be  applied  firmly  and  evenly  to  the  sur- 
29 


450  PHYSICAL   DIAGNOSIS 

face,  thus  preventing  the  slipping  of  the  soft  parts,  and  also  to 
determine  the  resistance  of  the  chest  walls  when  the  blow  is  given. 
The  rounded  ends  of  the  first  and  second  fingers  of  the  right  hand  are 
used  as  a  hammer,  striking  the  pleximeter  fingers  in  such  a  manner 
that  the  nails  shall  not  touch  the  skin  of  the  underlying  fingers. 
The  force  employed  varies  in  different  regions,  but  usually,  for  the 
chest,  should  be  only  of  moderate  degree.  Forcible  percussion  is  of 
use  only  when  the  sound  of  deep-seated  organs  is  desired. 

The  stroke  should  be  made  perpendicularly  to  the  surface,  and  not 
slanting,  as  is  too  often  done.  The  whole  movement  should  proceed 
only  from  the  wrist-joint,  and  ought  not  to  be  too  rapid  or  unequal, 
or  of  great  force,  the  fingers  being  rapidly  withdrawn,  so  as  not  to 
interfere  with  the  vibrations. 

The  objects  of  percussion  are  to  elicit  certain  sounds^  and  the 
amount  of  resistance  or  elasticity  of  the  organs  percussed. 

The  main  sounds  elicited  by  percussion  are  the  dull,  clear,  and 
tympanitic.  Familiarity  with  the  intensity,  character,  and  pitch  of 
each  of  these  sounds  is  essential. 

When  percussing  the  healthy  chest,  the  sound  obtained  is  termed 
the  normal  pulmonary  resonance.  It  is  of  variable  intensity,  depend- 
ing upon  the  force  of  the  stroke  employed  and  the  amount  of  adipose 
and  muscular  tissues  covering  the  thorax,  and  the  tension  of  the  chest 
walls. 

There  is  no  exact  standard  of  the  normal  pulmonary  or  vesicular 
resonance,  but  if  the  two  sides  of  the  chest  are  compared,  the  normal 
standard  of  each  person  is  obtained. 

The  character  is  termed  pulmonary  or  clear,  as  characteristic  of 
the  healthy  chest  wall.     The  pitch  is  always  relatively  low. 

The  sounds  elicited  by  percussing  a  healthy  chest  are  not,  however, 
alike  over  all  its  parts. 

Anteriorly,  the  portion  of  lung  above  the  clavicle  yields  a  sound 
which  becomes  somewhat  tympanitic  as  the  trachea  is  approached. 

Over  the  clavicle  the  sound  is  clear  and  pulmonary  at  the  center 
of  the  bone,  but  at  the  scapular  extremity  it  is  duller,  and  toward 
the  sternum  it  becomes  somewhat  tympanitic. 

At  the  infra-clavicular  region  the  resonance  is  clear  and  distinct, 
but  little  resistance  being  offered  to  the  percussing  finger,  and  the 
sound  elicited  may  be  taken  as  the  type  of  the  pulmonary  resonance. 
In  this  region,  however,  a  slight  disparity  exists  between  the  two 


PHYSICAL    DIAGNOSIS  45 1 

sides;  on  the  right  side  the  sound  is  less  clear,  shorter,  and  of  a 
higher  pitch  than  on  the  left  side. 

In  the  mammary  region  of  the  right  side  the  resonance  of  the  lung 
is  not  so  clear,  the  sound  being  modified  by  the  size  of  the  mamma 
and  the  upper  border  of  the  liver.  On  the  left  side  the  heart  deadens 
the  sound  from  the  fourth  to  the  sixth  rib,  and,  in  a  transverse  direc- 
tion, from  the  sternum  to  the  left  nipple.  This  dull  sound  in  the 
left  mammary  region  is  lessened  in  extent  during  full  inspiration, 
and  in  emphysema,  when  the  lung  more  completely  covers  the 
heart. 

In  the  infra-mammary  region  on  the  right  side  the  percussion- 
note  is  dull,  except  during  the  act  of  complete  inspiration,  when  the 
liver  is  displaced  downward  by  the  inflated  lung.  In  the  left  infra- 
mammary  region  the  sound  consists  of  a  mixture  of  the  dull  sound 
of  the  heart  and  spleen  and  of  the  clear  sound  of  the  lung,  together 
with  the  tympanitic  sound  of  the  stomach.  In  the  lower  part  of 
this  region  is  an  area  known  as  Traube's  semilunar  space,  over  which 
the  note  is  tympanitic.  It  is  bounded  above  by  the  sixth  rib  (cor- 
responding approximately  to  the  lower  border  of  the  left  lung),  on 
the  left  by  the  spleen,  and  on  the  right  by  the  liver. 

Over  the  upper  part  of  the  sternum — above  the  third  rib — the 
sound  is  slightly  tympanitic.  Below  the  third  rib,  over  the  sternum, 
the  sound  is  dull,  due  to  the  presence  of  the  heart  and  liver. 

The  position  exercises  some  influence  on  the  results  of  percussion. 
More  accurate  results  are  obtained  when  the  patient  is  standing  or 
sitting  than  when  recumbent.  While  the  front  of  the  chest  is  per- 
cussed, the  arms  should  hang  loosely  by  the  sides;  the  hands  may  be 
clasped  across  the  top  of  the  head  during  the  percussion  of  the 
axillary  region;  during  the  examination  of  the  back  the  head  must 
be  bent  forward  and  the  arms  tightly  crossed  in  front. 

On  the  posterior  surface  of  the  chest  the  sound  also  varies  according 
to  the  part  percussed. 

Over  the  scapula  the  sound  is  duller  than  between  these  bones 
or  below  their  inferior  angles. 

Over  the  infra-scapular  region  a  clear  sound  is  obtained  as  far 
as  the  lower  border  of  the  tenth  rib  on  the  right  side,  where  the  dull- 
ness of  the  liver  begins.  On  the  left  side,  below  the  angle  of  the  scap- 
ula, the  percussion-sound  is  tympanitic  if  the  intestines  are  distended, 
or  it  may  be  slightly  dull  if  the  spleen  is  enlarged. 

In  the  axillary  region  the  sound  is  clear  and  distinct  on  each  side. 


452  PHYSICAL   DIAGNOSIS 

In  the  infra-axillary  region  of  the  right  side  the  sound  is  duller, 
owing  to  the  presence  of  the  liver;  at  the  corresponding  situation  on 
the  left  side  the  sound  is  clear  or  tympanitic,  from  the  distention 
of  the  stomach,  and  at  the  ninth  or  tenth  rib  of  the  left  axillary 
region,  dullness  and  the  sense  of  resistance  mark  the  location  of 
the  spleen. 

The  sounds  obtained  by  percussion  of  the  unhealthy  or  abnormal 
chest  are  as  follows: 

1.  Hyper-resonance,  or  an  increase  of  the  normal  pulmonary 
resonance,  is  due  to  the  relative  increase  in  the  proportion  of  air  to 
the  solid  tissues  of  the  lung,  provided  the  tension  of  the  chest  walls 
be  not  altered.  It  occurs  in  emphysema  of  the  lungs,  atrophy  of 
the  lungs,  or  consolidation  of  the  opposing  lung. 

2.  Dullness  or  an  absence  of  resonance,  due  to  the  relative  increase 
of  solid  tissues  in  proportion  to  the  amount  of  air,  as  seen  in  the 
different  stages  of  phthisis,  in  pneumonia,  pleural  effusion,  and 
hydrothorax. 

The  pitch  is  increased  or  heightened  in  proportion  to  the  diminution 
of  the  amount  of  the  air  and  the  increase  of  the  solids. 

If  there  be  entire  want  of  resonance,  the  percussion-note  is  said 
to  be  flat;  if  there  is  a  slight  decrease  in  the  resonance  of  the  part, 
the  note  is  said  to  be  impaired. 

The  sense  of  resistance  is  greater  the  more  marked  the  consolida- 
tion of  the  lungs  and  the  greater  the  tension  of  the  chest  walls. 

3.  Tympanitic,  or  the  drum-like  percussion-note,  is  a  nonvesicular 
sound  having  the  character  elicited  by  percussing  over  the  normal 
intestines ;  wherever  heard  it  indicates  the  presence  of  air  in  conditions 
similar  to  that  of  the  intestines,  namely,  inclosed  in  walls  which  are 
yielding,  but  neither  tense  nor  very  thick. 

When  elicited  over  the  chest  it  may  be  due  to  the  transmitted 
sound  of  the  distended  stomach  or  colon.  It  is  obtained  over  the 
chest  in  pneumothorax,  in  moderate  pleural  effusions  above  the 
level  of  the  liquid,  over  the  seat  of  cavities  in  the  pulmonary  tissue, 
and  in  emphysema  of  the  lungs. 

The  tympanitic  percussion-note  differs  from  the  normal  pulmonary 
resonance  in  being  more  ringing  in  character  and  of  a  higher  pitch. 

The  amphoric  or  metallic  sound  is  in  reality  a  concentrated  tym- 
panitic sound  of  high  pitch,  and  denotes  a  large  cavity  with  firm,  but 
yet  elastic,  walls. 

The  cracked-pot  or  cracked-metal  sound  is  another  variety  of  the 


PHYSICAL   DIAGNOSIS  453 

tympanitic  sound.  The  condition  most  frequently  producing  this 
sound  is  a  cavity  in  the  lung  tissue,  communicating  with  a  bronchial 
tube.  It  requires  for  its  development  a  strong,  quick  blow  of  the 
percussing  finger,  with  the  patient's  mouth  open. 

Respiratory  Percussion. — The  percussion-sound  will  vary  greatly 
with  the  respiratory  movements.  If  a  full  inspiration  be  taken  and 
percussion  performed,  then  a  ful)  expiration  taken  and  percussion 
performed,  and  then  the  chest  percussed  during  the  normal  respira- 
tion, slight  changes  in  the  character  and  pitch  of  the  note  are 
obtained,  which  otherwise  would  escape  detection.  DaCosta  has 
designated  this  method,  respiratory  percussion. 

Auscultatory  Percussion. — This  method  consists  in  listening,  with 
a  stethoscope  applied  to  the  thorax,  to  the  sounds  elicited  by  percus- 
sion. "It  is  a  serviceable  means  of  determining  with  accuracy  the 
boundaries  of  various  organs,  as  those  of  the  lungs  or  heart,  or  of  the 
liver  or  spleen,  and  yields  particularly  exact  results  when  carried  out 
with  the  double  stethoscope." 

AUSCULTATION 

Auscultation,  or  listening  to  the  sounds  produced  within  the  chest 
during  the  act  of  respiration,  coughing,  or  speaking,  furnishes  the 
most  reliable  means  of  studying  the  condition  of  the  lungs  and  heart, 
and  is,  therefore,  the  most  valuable  method  of  discriminating  between 
the  various  conditions  which  may  affect  the  lungs  and  heart. 

Auscultation  is  either  immediate  or  mediate. 

It  is  immediate  when  the  ear  is  applied  directly  to  the  chest,  which 
may  be  either  denuded  or  thinly  covered. 

It  is  mediate  when  the  sounds  are  conducted  to  the  ear  by  means  of 
a  tubular  instrument,  termed  a  stethoscope. 

For  ordinary  purposes,  immediate  or  direct  auscultation  is  suflficient, 
but  when  it  is  desirable  to  analyze  circumscribed  sounds,  as  in  dis- 
eases of  the  heart,  or  where  the  patient  objects  to  this  method,  on  the 
score  of  delicacy,  or  the  auscultator  objects,  on  account  of  the  unclean- 
liness  of  the  person  examined,  the  stethoscope  is  to  be  preferred. 
Moreover,  there  are  certain  parts  of  the  chest  which  can  only  be 
explored  satisfactorily  by  the  aid  of  a  stethoscope,  which  instrument 
has  the  additional  advantage  of  intensifying  the  sound. 

In  auscultation,  the  following  rules,  formulated  by  DaCosta, 
should  be  observed : 


454  PHYSICAL   DIAGNOSIS 

''  I.  Place  yourself  and  your  patient  in  a  position  which  is  the  least 
constrained  and  permits  of  the  most  accurate  application  of  the  ear  or 
stethoscope  to  the  surface.  Above  all,  avoid  stooping,  or  having  the 
head  too  low. 

"2.  Let  the  chest  be  bare,  or  what  is  better,  covered  only  with  a 
towel  or  thin  shirt. 

"3.  If  a  stethoscope  be  employed,  apply  closely  to  the  surface,  but 
abstain  from  pressing  with  it.  This  may  be  obviated  by  steadying 
the  instrument,  immediately  above  its  expanded  extremity,  between 
the  thumb  and  the  index  finger. 

"4.  Examine  repeatedly  the  different  portions  of  the  chest,  and 
compare  them  with  one  another  while  the  patient  is  breathing  quietly. 
Making  him  cough  or  draw  a  full  breath  is  at  times  of  service;  espe- 
cially the  former,  when  he  does  not  know  how  to  breathe." 

SOUNDS   IN   HEALTH 

If  the  ear  be  applied  over  the  larynx  or  trachea  of  a  healthy  per- 
son, a  sound  is  heard  with  both  the  act  of  inspiration  and  expiration. 
Its  intensity  is  variable,  its  pitch  high,  and  its  quality  tubular  (that  is, 
like  a  current  of  air  passing  through  a  tube — the  larynx  or  trachea) . 
The  duration  of  the  sound  during  inspiration  is  somewhat  longer  than 
during  expiration.     A  short  pause  follows  the  act  of  expiration. 

This  sound  is  termed  the  normal  laryngeal  respiration,  and  is  iden- 
tical in  character,  duration,  and  pitch  with  an  important  morbid  sound, 
termed  bronchial  respiration. 

The  sound  heard  by  placing  the  ear  over  the  lung-tissue  is  different ; 
it  is  produced  in  the  very  finest  bronchial  tubes  and  air-cells  by  their 
expansion  and  contraction,  and  is  termed  the  normal  vesicular  murmur. 

The  inspiratory  portion  of  the  sound  is  of  variable  intensity,  its 
pitch  is  low,  its  quality  soft  and  breezy,  designated  vesicular;  its 
duration  corresponds  to  that  of  the  entire  act  of  inspiration. 

The  expiratory  portion  of  the  sound  is  not  always  perceptible;  it  is 
of  feeble  intensity,  very  low  pitch,  its  character  soft  and  blowing,  and 
its  duration  much  less  than  the  act  of  inspiration. 

It  is  to  be  remembered,  however,  that  the  vesicular  murmur  will  be 
found  to  vary  in  the  different  regions  on  the  same  side,  and  in  cor- 
responding regions  on  the  two  sides  of  the  chest.  These  variations 
within  the  range  of  health  are  especially  important,  and  should  be 
memorized. 


PHYSICAL   DIAGNOSIS  455 

Infra-clavicular  Regions. — The  vesicular  murmur  in  this  region  on 
either  side  is  much  more  distinct  than  over  any  other  part  of  the 
chest. 

On  the  left  side  the  inspiratory  sound  is  of  greater  intensity,  of 
lower  pitch,  and  more  distinctly  vesicular  in  quality  than  that  heard 
upon  the  right  side.  On  the  right  side  the  expiratory  sound  is  nearly 
or  quite  the  same  in  length  as  the  inspiratory  sound,  and  is  higher  in 
pitch  and  more  tubular  in  quality  than  the  expiratory  sound  upon  the 
left  side. 

Supra- scapular  Region. — Owing  to  the  small  number  of  air-vesicles 
and  the  large  number  of  bronchial  tubes,  and  their  close  proximity  to 
the  surface,  the  respiratory  murmur  has  an  intense,  high-pitched, 
tubular,  and  expiratory  quality. 

Scapular  Region. — Compared  with  the  infra-clavicular  region,  the 
respiratory  murmur  heard  over  the  scapula  on  either  side  is  more 
feeble,  and  the  vesicular  quality  less  marked. 

Inter-scapular  Region. — The  murmur  in  this  region  differs  from  the 
normal  laryngeal  breathing  only  in  intensity  and  duration. 

Infra-scapular  Region. — The  murmur  in  this  region  very  closely 
resembles  that  heard  in  the  left  infra-clavicular  region. 

Mammary  and  Infra-mammary  Regions. — The  murmur  in  these 
regions  differs  from  that  heard  in  the  infra-clavicular  region,  in 
being  of  less  intensity. 

Axillary  and  Infra-axillary  Regions. — The  respiratory  sound 
in  the  axillary  regions  is  as  intense  as  in  any  portion  of  the  chest. 
In  the  infra-axillary  regions  the  intensity  is  less  and  the  pitch  lower. 

VOICE   IN  HEALTH 

If  the  ear  be  applied  over  the  larynx  or  trachea  of  a  healthy  person 
and  he  be  directed  to  count  "twenty-one,  twenty-two,  twenty-three," 
in  a  uniform  tone  and  with  moderate  force,  there  is  perceived  a  strong 
resonance,  with  a  sensation  of  concussion  or  shock,  and  a  sense  of 
vibration,  thrill,  or  fremitus,  the  voice  seeming  to  be  concentrated 
and  near  the  ear.  Often  the  articulated  words  are  distinctly  trans- 
mitted (laryngophony) . 

The  sounds  heard  are  termed  the  normal  laryngeal  resonance. 

If  the  ear  or  stethoscope  be  applied  over  the  third  rib  anteriorly, 
on  either  side  of  the  chest  of  a  healthy  person,  and  he  be  directed  to 
count  ''twenty-one,  twenty-two,  twenty- three,"  in  a  uniform  tone, 


456  PkYSICAL   DIAGNOSIS 

with  moderate  force,  a  confused  distant  hum  is  perceived  of  variable 
intensity,  accompanied  with  more  or  less  vibration,  thrill,  or  fremitus, 
most  distinct  in  adults,  but  notably  weaker  in  women  than  in  men. 

This  sound  is  termed  the  normal  vocal  resonance. 

If  the  ear  or  stethoscope  be  applied  over  the  third  rib  anteriorly, 
of  a  healthy  person,  and  he  be  directed  to  whisper,  in  a  uniform  manner 
the  words  '^twenty-one,  twenty-two,  twenty-three,"  there  is  heard 
a  sound  corresponding  closely  in  character  to  the  sound  of  expira- 
tion over  the  same  region  during  the  act  of  forced  respiration;  or, 
in  other  words,  a  feeble,  low-pitched,  blowing  sound. 

This  sound  is  termed  the  normal  bronchial  whisper,  and  is  produced 
by  the  movement  of  the  air  in  the  bronchial  tubes  during  the  act 
of  respiration. 

SOUNDS   IN   DISEASE 

The  vesicular  murmur  may  undergo,  in  disease,  changes  in  its 
intensity,  its  rhythm,  and  in  its  character. 

The  intensity  of  the  respiratory  murmur  may  be: 

1.  Exaggerated  or  increased. 

2.  Diminished  or  feeble. 

3.  Absent  or  suppressed. 

Exaggerated  respiration  differs  from  the  normal  vesicular  respira- 
tion only  in  an  increase  in  the  intensity  of  the  respiratory  sounds. 
When  general  over  one  lung,  it  will  usually  indicate  deficient  action 
of  other  parts.  In  this  manner  an  effusion  compressing  the  lung, 
one-sided  deposits,  obstruction  of  the  bronchial  tubes  by  secretion, 
or  inflammation  of  the  lung-structure,  necessitate  a  supplementary 
respiration  in  a  healthy  portion  of  the  same  lung  or  the  lung  upon 
the  opposite  side.  From  its  resemblance  to  the  loud,  strong,  quick 
respiration  of  young  children,  it  has  been  termed  puerile  respiration. 
Exaggerated  respiration  is,  therefore,  to  be  regarded  as  indirect  evi- 
dence of  disease  in  some  portion  of  the  pulmonary  tissue. 

Diminished  respiration,  called  also  senile  respiration,  as  being 
characteristic  of  old  age,  is  characterized  by  diminished  intensity 
and  duration  of  the  sound.  In  the  large  majority  of  instances  the 
inspiration  suffers  the  greatest,  the  expiratory  sound  not  diminishing 
in  the  same  proportion.  In  asthma,  emphysema,  diseases  of  the 
larynx  and  bronchial  tubes,  pleuritic  pain,  rheimiatism  or  paralysis 
of  the  chest  walls,  or  in  thickening  of  the  pleural  membrane,  we  ob- 


PHYSICAL   DIAGNOSIS  457 

serve  superficial  or  diminished  respiration.  When  one  side  of  the 
chest  is  partially  filled  with  fluid,  we  may  hear  a  deep-seated  but 
feeble  breath  sound. 

Absent  or  suppressed  respiration  occurs  whenever  the  action  of 
the  lung  is  suspended;  this  may  be  from  external  pressure,  as  when 
the  lung  is  compressed  by  the  presence  of  fluid  or  air  in  the  pleural 
cavity,  or  when  complete  obstruction  of  the  bronchial  tubes  prevents 
the  air  from  either  entering  or  escaping  from  the  lungs. 

The  rhythm  of  the  respiratory  murmur  may  be : 

1.  Interrupted  or  jerky. 

2.  The  interval  between  inspiration  and  expiration  prolonged. 

3.  Expiration  prolonged. 

In  health  the  inspiratory  and  expiratory  sounds  are  even  and 
continuous,  with  a  short  interval  between  each  act;  this  may  be 
altered  in  disease,  and  both  sounds,  especially  the  inspiratory,  have 
an   interrupted  or  jerky  character,  termed  '' cog-wheel  respiration." 

This  jerky  breathing  is  noted  in  some  spasmodic  affections  of  the 
air-tubes,  in  hysteria,  the  earliest  stages  of  pleurisy,  pleurodynia, 
and  the  early  stages  of  pulmonary  phthisis.  It  is  most  frequently 
associated  with  phthisis,  due  probably  to  the  adhering  to  the  walls 
of  the  finer  bronchial  tubes  of  tough  mucus,  which  obstructs  the 
free  entrance  and  exit  of  the  air;  it  is  usually  most  notable  under  the 
clavicles. 

The  interval  between  inspiration  and  expiration  may  be  prolonged, 
instead  of  these  two  sounds  closely  succeeding  each  other.  When 
this  occurs  the  inspiratory  sound  may  be  shortened,  or  the  expiratory 
sound  may  be  delayed  in  its  commencement.  If  the  inspiratory 
sound  is  shortened,  it  is  the  result  of  consolidation  of  the  lungs; 
if  the  expiratory  sound  is  delayed,  it  is  the  result  of  lessened  elas- 
ticity of  the  lung-structure,  and  is  most  commonly  associated  with 
emphysema. 

Prolonged  expiration  denotes  that  the  air  is  obstructed  in  its 
exit  from  the  lungs.  It  may  be  due  to  diminished  elasticity,  the 
result  of  emphysema,  or  from  the  deposit  of  tubercles,  which  impair 
the  contractile  power  of  the  lungs.  If  the  former,  it  is  associated 
with  clearness  on  percussion;  if  the  latter,  with  impaired  resonance 
on  percussion.  When  prolonged  expiration  is  detected  at  the  apex 
of  the  lung,  and  is  associated  with  impairment  of  the  normal  pul- 
monary resonance,  it  is  for  the  most  part  the  result  of  a  tuberculous 
deposit. 


458  PHYSICAL   DIAGNOSIS 

The  quality  of  the  respiratory  murmur  may  be: 

1.  Harsh,  termed  broncho-vesicular  respiration. 

2.  Bronchial. 

3.  Cavernous. 

4.  Amphoric. 

Harsh  respiration,  or,  as  it  is  termed  broncho-vesicular  respira- 
tion is  that  variety  in  which  both  the  inspiratory  and  expiratory 
sounds  have  lost  their  natural  softness.  It  generally  indicates 
more  or  less  consolidation  of  lung-tissue.  In  normal  vesicular 
respiration  the  sounds  produced  by  the  air  expanding  the  air-cells 
and  finer  bronchial  tubes  obscure  the  sound  produced  by  the  pas- 
sage of  air  through  the  larger  bronchial  tubes,  the  healthy  lung  being 
an  imperfect  conductor  of  sound,  so  that  as  soon  as  any  portion  of  the 
lung  becomes  consolidated  the  vesicular  element  of  the  respiratory 
sound  is  diminished,  the  bronchial  element  becoming  promment. 
Harsh  respiration  is,  then,  a  union  of  the  vesicular  and  bronchial 
sounds,  being  a  vesicular  sound  mixed  with  some  of  the  qualities  of  a 
bronchial  sound,  the  expiration  being  prolonged  and  tubular  in 
character.  It  is  present  when  the  bronchial  mucous  membrane  is 
swollen,  as  in  the  earlier  stages  of  bronchitis,  also  in  the  earlier  stages 
of  phthisis  and  pneumonia. 

Bronchial  respiration  is  characterized  by  an  entire  absence  of  all 
the  vesicular  quality.  Inspiration  is  of  high  pitch  and  tubular  in 
character;  expiration  is  still  higher  in  pitch,  of  greater  intensity, 
prolonged  and  tubular  in  quality;  the  two  sounds  being  separated 
by  a  brief  interval.  The  bronchial  respiration  encountered  in  disease 
closely  resembles  that  heard  in  health  over  the  larynx  or  trachea. 
Whenever  bronchial  respiration  is  present  where,  in  health,  the  normal 
vesicular  murmur  should  be  heard,  it  indicates  consolidation  of  the 
lung-structure. 

Cavernous  respiration  is  a  variety  of  the  bronchial  respiration,  at 
least  so  far  as  the  quality  of  the  sound  is  concerned.  It  is  essentially 
a  blowing  sound,  yet  not  always  heard  during  both  the  acts  of  inspira- 
tion and  expiration,  being  often  only  perceptible  in  the  one,  and  in  the 
other  mixed  with  gurgling  sounds.  Its  pitch  is  lower  than  that  of 
ordinary  bronchial  respiration,  and  its  character  is  hollow.  For  its 
production  there  must  be  a  cavity  of  considerable  size  in  the  lung- 
substance,  not  filled  with  fluid,  near  the  surface  of  the  chest-walls, 
communicating  with  a  bronchial  tube.  It  is  met  with  most  com- 
monly in  the  last  stages  of  pulmonary  consumption,  although  hollow 


PHYSICAL   DIAGNOSIS  459 

spaces  of  any  kind,  from  abscess  or  dilatation  of  the  bronchial  tubes, 
occasion  it. 

Amphoric  respiration  is  a  blowing  respiration,  having  a  musical 
or  metallic  quality.  It  is  a  variety  of  bronchial  respiration  produced 
in  a  large  cavity  with  firm  walls,  permitting  the  reflection  of  the  sound. 
An  imitation  of  this  sound,  though  only  an  imperfect  one,  is  pro- 
duced by  blowing  over  the  mouth  of  an  empty  bottle.  The  am- 
phoric character  is  present  with  both  the  acts  of  inspiration  and  ex- 
piration. Amphoric  or  metallic  respiration  is  indicative  of  a  large 
cavity,  not  common  in  phthisis,  but  more  often  heard  at  the  upper 
part  of  a  lung  compressed  by  fluid  air,  as  in  pneumo-hydrothorax. 

RALES 

Rales,  or,  as  they  are  termed,  adventitious  sounds,  because  they 
have  no  analogue  in  the  healthy  state,  cannot  be  considered  as 
modifications  of  the  normal  respiration. 

Grouped  according  to  the  anatomical  situation  in  which  they 
are  produced,  we  have: 

1.  Laryngeal  and  tracheal  rales. 

2.  Bronchial  rales. 

3.  Vesicular  rales. 

4.  Cavernous  rales. 

5.  Pleural  rales. 

Rales  may  be  divided  into  two  groups,  according  to  their  character, 
dry  and  moist;  and  may  be  audible  either  during  the  act  of  inspiration 
or  expiration,  or  during  both. 

Dry  rales,  for  the  most  part,  are  produced  by  the  vibration  of 
thick  fluids  which  the  air  cannot  break  up,  and  which  therefore, 
temporarily  lessen  the  caliber  of  the  bronchial  tubes.  When  this 
narrowing  exists  in  the  smaller  bronchial  tubes  the  resulting  sound 
is  high-pitched  or  the  rale  is  said  to  be  sibilant  or  whistling;  when  the 
narrowing  exists  in  the  larger  bronchial  tubes,  the  rale  is  low-pitched, 
more  musical  in  character,  or  sonorous. 

Dry  rMes  are  particularly  prone  to  be  dislodged  by  coughing, 
and  when  they  are  uninfluenced  by  the  acts  of  breathing  and  coughing, 
they  do  not  depend  upon  the  presence  of  secretions,  but  upon  the 
narrowing  of  the  air -tubes  from  the  pressure  of  tumors,  or  from  a 
thickened  fold  of  mucous  membrane,  or  from  a  spasmodic  contrac- 
tion of  the  air-tubes. 


460  PHYSICAL    DIAGNOSIS 

Moist  rales  are  those  produced  by  the  air  passing  through  thin 
fluids,  such  as  mucus,  blood,  serum,  or  pus,  during  the  respiratory 
movements.  When  the  fluid  exists  in  the  smaller  bronchial  tubes, 
the  rales  are  termed  small  bubbling,  mucous,  or  subcrepitant.  When 
the  fluid  is  in  the  large  bronchial  tubes,  the  rales  are  said  to  be  large 
bubbling  or  mucous. 

Moist  rales  are  not  persistent,  but  vary  in  intensity,  and  shift 
their  position  as  the  air  drives  the  liquid  which  occasions  them 
before  it,  during  violent  attacks  of  coughing,  or  after  copious 
expectoration. 

Laryngeal  and  tracheal  rales  are  those  produced  within  the  larynx 
or  trachea,  and  may  be  either  moist  or  dry.  The  moist  or  bubbling 
sounds,  produced  when  mucous  or  other  liquids  accumulate  in  this 
part  of  the  air-tubes,  frequently  occur  in  the  moribund  state,  and  are 
then  known  as  the  ^^ death  rattle."  When  not  due  to  this  condition 
they  denote  either  insensibility  to  the  presence  of  liquid,  as  in  stupor 
or  coma,  or  inability  to  remove  liquid  by  the  act  of  expectoration, 
as  in  croup  or  inflammation  of  these  parts  in  the  very  feeble. 

The  dry  rales  produced  within  the  larynx  or  trachea  are  generally 
caused  by  spasm  of  the  glottis  as  in  laryngismus  stridulus,  whooping 
cough,  croup,  or  from  the  presence  of  a  foreign  body  in  the  part. 

Bronchial  rales,  resulting  from  the  passage  of  air  through  the 
thin  liquid,  occasion  bubbling  sounds.  When  the  liquid  is  present 
in  the  large-sized  bronchial  tubes,  the  rales  are  said  to  be /ar^e  bubbling, 
or  large  mucous  rMes,  occurring  in  acute  or  chronic  bronchitis.  When 
the  liquid  is  in  the  smaller  bronchial  tubes,  the  resulting  rale  is  called 
small  bubbling,  small  mucous  or  subcrepitant,  also  occurring  in  acute 
or  chronic  bronchitis.    ' 

Bronchial  r^les,  due  to  the  narrowing  of  the  tube  by  its  spas- 
modic contraction,  or  to  the  presence  of  tough,  tenacious  mucus, 
which  is  put  into  vibration  by  the  passage  of  air  through  the  bron- 
chial tubes,  are  termed  dry  bronchial  rales.  Frequently  they  are 
suggestive  of  certain  familiar  sounds  such  as  snoring,  cooing,  hum- 
ming, or  wheezing,  or  they  are  often  mtisical  tones.  When  produced 
in  the  smaller  bronchial  tubes,  they  are  termed  sibilant,  or  high- 
pitched  rales ;  when  produced  in  the  larger  bronchial  tubes,  they  are 
termed  sonorous  or  low-pitched  rales.  They  principally  occur  in  the 
dry  stage  of  bronchitis,  or  during  an  asthmatic  paroxysm. 

The  vesicular  rale,  or,  as  it  is  more  commonly  termed,  the  crepitant 
rale,  is  produced  within  the  air-vesicles  or  ai  the  terminal  portion 


PHYSICAL   DIAGNOSIS  46 1 

of  the  smaller  bronchial  tubes.  It  is  to  be  distinguished  from  very 
fine  bubbling  sounds,  or  the  subcrepitant  r§,le.  ''It  is  a  very  fine 
sound  or  rather  series  of  very  fine  uniform  sounds,  occurring  in  pufis 
and  limited  to  inspiration^^  (DaCosta).  It  resembles  the  noise 
occasioned  by  throwing  salt  on  fire,  or  alternately  pressing  and 
separating  the  thumb  and  finger,  moistened  with  a  solution  of  gum 
arable,  and  held  near  the  ear,  or  rubbing  together  a  lock  of  dry  hair 
near  the  ear. 

The  crepitant  rale  is  produced  by  the  movement  of  fluid  in  the 
air-cells  or  in  the  finest  extremities  of  the  bronchial  tubes,  or  by 
the  forcing  open,  during  the  act  of  inspiration,  of  the  air-cells  agglu- 
tinated by  exuded  lymph.  These  sounds  may  be  defined  as  being 
very  fine,  dry,  crackling  sounds,  heard  at  the  end  of  inspiration 
only.  They  are  usually  present  in  the  first  stages  of  pneumonia, 
but  when  limited  to  the  apices  are  significant  of  the  incipient  stage 
of  phthisis;  they  are  also  heard  in  pulmonary  edema  and  in 
atelectasis. 

Cavernous  rales,  or,  as  they  are  commonly  termed,  gurgling  rales, 
are  produced  in  a  pulmonary  cavity  of  considerable  size,  containing 
a  large  amount  of  liquid  communicating  freely  with  a  bronchial 
tube.  The  sound  is  occasioned  by  the  agitation  of  the  liquid  within 
the  cavity,  and  may  be  compared  to  the  sound  produced  by  the  boil- 
ing of  liquid  in  a  flask  or  large  test-tube.  The  sound  is  sometimes 
high-pitched  or  musical,  whence  it  has  been  termed  "amphoric  gur- 
gling," but  it  is  generally  low  in  pitch.  The  rale  is  heard  almost  ex- 
clusively during  the  act  of  inspiration,  and  its  diagnostic  importance 
relates  to  the  advanced  stage  of  phthisis. 

Pleural  rales  may  be  either  dry  or  moist. 

Dry  pleural  rales,  or,  as  they  are  more  commonly  termed,  friction 
sounds,  are  occasioned  when  the  surfaces  of  the  pleura  are  covered 
with  a  glutinous  substance  preventing  the  unobstructed  movements 
of  the  pleural  surfaces  upon  each  other  during  the  respiratory  acts, 
for  in  health  these  movements  occasion  no  sound  whatever.  The 
sounds  are  generally  interrupted  or  irregular,  occurring  during  the 
act  of  inspiration  or  expiration,  or  during  both  acts.  The  character 
of  the  sound  is  variable,  being  termed  rubbing,  grazing,  rasping, 
grating,  or  creaking,  according  to  the  intensity  of  the  respiratory  acts 
and  the  amount  of  exudation. 

They  are  distinguished  by  the  apparent  nearness  of  the  sound  to 
the  ear,  and  are  usually  intensified  by  firm  pressure  of  the  stethoscope 


462  PHYSICAL   DIAGNOSIS 

upon  the  chest.  When  the  chest  is  fixed,  especially  at  the  lower  two- 
thirds,  and  the  ear  applied  over  the  seat  of  the  sound,  it  will  be  found 
to  have  disappeared.  The  sound  is  diagnostic  of  the  first  stage 
of  pleurisy  or  the  preadhesive  stage  of  tuberculosis  of  the  pleura. 

Moist  friction  sounds  are  produced  in  the  same  manner  as  those 
just  mentioned,  the  exudation  being  softened  in  character.  This 
sound  is  frequently  confounded  with  moist  bronchial  rMes,  and  its 
discrimination  is  often  only  positive  by  careful  study  of  the  symptoms 
and  concomitant  signs  present. 

Metallic  tinkling  is  a  sign  of  pneumothorax  with  perforation  of 
the  lung,  and  when  found,  is  usually  diagnostic  of  this  affection, 
although  it  occurs  rarely  in  cases  of  phthisis  with  a  large  cavity,  the 
physical  conditions  for  its  production  being  similar  to  those  in 
pneumothorax,  namely,  a  space  of  considerable  size  containing  air 
and  liquid,  the  space  communicating  with  the  bronchial  tubes. 

It  consists  of  a  series  of  tinkling  sounds  of  high  pitch,  silvery  or 
metallic  in  tone,  and  is  very  well  imitated  by  dropping  a  small  marble 
into  a  metallic  vase.  It  occurs  .irregularly,  not  being  present  with 
every  act  of  breathing,  and  may  be  produced  by  force,  when  not 
heard  during  tranquil  breathing.  When  it  is  low-pitched  it  is  some- 
times called  amphoric  tinkling. 

Were  it  not  for  the  location  and  the  absence  of  concomitant 
signs,  it  might  be  confounded  with  tinkling  sounds  sometimes  pro- 
duced within  the  stomach  and  transverse  colon;  these  latter  sounds 
must  be  kept  in  mind  in  auscultating  the  lower  chest  area. 

THE  VOICE  IN  DISEASE 

The  normal  vocal  resonance,  as  heard  over  the  third  rib  of  the 
chest  anteriorly  on  each  side,  may  have  its  intensity — 

1.  Diminished  or  absent. 

2.  Increased  or  exaggerated. 

Or  its  resonance  may  be  of  the  character  of — 

3.  Bronchophony. 

4.  Pectoriloquy. 

5.  Ego  phony. 

6.  Amphoric  voice. 

The  vocal  resonance  may  be  diminished  or  feeble  in  bronchitis 
with  free  secretion,  pleurisy  with  effusion,  or  in  complete  consolida- 
tion of  the  lung -structure  and  the  bronchial  tubes. 


PHYSICAL   DIAGNOSIS  463 

The  vocal  resonance  is  absent  in  pneumothorax  and  in  pleurisy 
with  effusion. 

Exaggerated  vocal  resonance  differs  from  the  normal  vocal  reso- 
nance in  a  slight  increase  of  its  density.  It  denotes  a  slight  degree 
of  solidification  of  lung-tissue,  and  is  chiefly  of  value  in  the  diagnosis 
of  tuberculosis. 

Bronchophony,  or  the  voice  concentrated  near  the  ear,  raised  in 
pitch  and  in  intensity,  denotes  complete  consolidation  of  the  pulmon- 
ary tissue  in  those  parts  in  which  the  sotmd  is  abnormally  present. 

Pectoriloquy  is  complete  transmission  of  the  voice  to  the  ear,  the 
articulated  words  being  distinctly  recognized.  It  has  a  close  re- 
semblance to  the  resonance  heard  over  the  larynx  in  health.  Its 
presence  indicates  either  a  pulmonary  cavity  or  more  complete 
consolidation — in  other  words,  an  exaggerated  bronchophony. 

Egophony  is  a  modification  of  bronchophony,  consisting  in  tremu- 
lousness  of  the  voice,  its  character  nasal  or  bleating,  somewhat 
suggestive  of  the  cry  of  a  goat.  When  heard  it  may  be  considered  a 
sign  of  pleurisy  with  slight  effusion,  or  pleuropneumonia. 

Amphoric  voice,  or  ''the  echo,"  as  it  is  sometimes  called,  is  a 
musical  sound,  of  a  somewhat  hollow,  metallic  character,  like  that 
produced  by  blowing  into  an  empty  bottle.  It  is  sometimes  pro- 
duced in  large  cavities  within  the  lung,  but  is  especially  incident  to 
pneumothorax. 

Increased  bronchial  whisper  is  a  sound  in  which  the  whispered 
words  are  abnormally  intense,  and  higher  in  pitch  than  the  normal 
bronchial  whisper.  It  has  the  same  significance  as  exaggerated 
vocal  resonance. 

SUCCUSSION 

The  succussion  or  splashing  sound  is  pathognomonic  of  one 
affection — namely,  pneumohydro thorax . 

It  is  obtained  by  jerking  the  body  of  the  patient  with  a  quick, 
somewhat  forcible  movement,  the  ear  being  very  near  or  in  contact 
with  the  chest. 

The  sound  is  like  that  produced  when  a  small  keg,  partially  filled 
with  liquid,  is  shaken.  The  only  liability  to  error  is  in  confound- 
ing this  splashing  sound  with  that  sometimes  produced  within  the 
stomach;  but  attention  to  concomitant  signs  and  the  symptoms  will 
always  protect  against  this  error. 


464 


ASSOCIATION    OF    THE   PHYSICAL    SIGNS 


ASSOCIATION  OF  THE  PHYSICAL  SIGNS 

(da  costa) 

"As  many  of  the  signs  elicited  by  the  various  methods  of  physical 
d  iagnosis  depend  on  the  same  physical  conditions,  they  may  be  studied 
in  groups.     The  following  will  be  usually  found  to  be  associated. 


Percussion 


Ascultation  of 
respiration 


Auscultation 
voice 


of 


Vocal 
fremitus 


Physical  condi- 
tions 


Clear. 


Dull. 


Tympanitic. 


Vesicular  mur- 
mur or  its  modi- 
fication. 


Bronchial  _  or 
harsh  respira- 
tion. 

Absent  respira- 
tion. 

Cavernous  or 

feeble,  accord- 
ing to  cause. 


Normal         vocal 
resonance. 


Bronchophony 


Absent  voice. 

Uncertain;  caver- 
nous or  dimin- 
ished. 


Amphoric  or  Amphoric  or  me-J  Amphoric  or  me- 
metallic tallic.  _  i     tallic. 

Cracked-metal  <  Cavernous  respi-j  Cavernous  respi- 
sound i     ration.  ration. 


Unimpaired. 


Increased. 


Diminished 
or  absent. 

U  ncer  tain; 
chiefly  di- 
minished. 


Mostly       di- 
minished. 
Uncertain. 


Lung-tissue 
healthy  or  nearly 
so;  at  any  rate, 
no  increased  den- 
sity from  deposits 
etc._ 

Solidification  of 
pulmonary  struc- 
ture. 

Effusion  into 

pleural  sac. 

Increased  _  quan- 
tity of  air  within 
the  chest,  due 
to  a  cavity  or  to 
overdistention  of 
the  air-cells. 

Large  cavity  with 
elastic  walls. 

Generally  a 
cavity  commu- 
nicating with  a 
bronchial  tube. 


GENERAL  SYMPTOMATOLOGY 

Dyspnea  (or,  as  patients  often  call  it,  '' shortness  of  breath")  is 
the  term  used  to  denote  difficult  or  impaired  breathing.  It  may  be 
inspiratory,  expiratory,  or  both;  and  there  may  be  an  increase  in 
frequency,  or  depth,  or  both,  of  the  respirations.  It  is  attended 
by  varying  degrees  of  distress  and  when  its  severity  requires  the 
patient  to  sit  up  constantly  it  is  called  orthopnea. 

Dyspnea  may  be  due  to  obstruction  of  the  air-passages,  pressure 
upon  the  respiratory  system  from  without  by  tumors,  and  distention 
of  abdomen,  diseases  of  the  lungs  and  pleura,  heart  disease,  asthma, 
anemia,  or  paralysis  of  muscles  of  respiration  as  the  result  of  hemor- 
rhage, tumors,  or  degeneration  of  the  respiratory  center  in  the  medulla 
or  toxic  agents  in  the  blood. 

It  may  be  inspiratory  when  it  results  from  obstruction  as  in  foreign 
bodies  in  the  larynx  or  trachea,  or  it  may  be  expiratory  as  in  emphy- 
sema, or  bronchial  asthma.  A  combination  is  the  more  frequent 
condition. 


GENERAL   SYMPTOMATOLOGY  465 

In  all  forms  of  dyspnea  it  is  important  to  determine  whether  the 
shortness  of  breath  bears  any  relation  to  exertion.  Dyspnea  inde- 
pendent of  exertion  is  a  serious  condition  and  is  symptomatic  of  severe 
cardiac  and  pulmonary  disease.  Dyspnea  dependent  upon  exertion 
is  less  serious  and  is  observed  in  health,  simple  debility,  anemia, 
obesity  and  somewhat  moderate  cardiac  debility. 

The  rate  of  respiration  varies  greatly  in  dyspnea.  Normally  the 
respiratory  rate  is  about  18  per  minute  in  adult  males,  being  some- 
what more  rapid  in  women  and  children.  Dyspnea  with  slow  or 
normal  breathing  is  observed  in  diabetic  coma,  and  again  the  breath- 
ing may  be  slow  and  stertorous  as  in  coma  of  central  origin.  Rapid 
respiration  occurs  in  inflammatory  pulmonary  disease,  pleurisy, 
painful  affections  of  the  chest  muscles,  heart  disease,  fever,  hysteria, 
toxic  conditions  affecting  the  respiratory  centers,  anemia,  and  morbid 
conditions  at  the  base  of  the  brain.  Irregularity  in  the  respiratory 
rate  in  dyspnea  may  also  be  observed.  Cheyne-Stokes  breathing  is 
the  term  applied  to  this  condition  when  the  respirations  gradually 
increase  in  rapidity  and  depth  until  a  climax  is  reached,  after  which 
there  is  a  period  of  apnea  or  absence  of  breathing.  The  paroxysm 
is  then  repeated.  It  is  a  serious  indication  and  may  be  observed  in 
meningitis,  apoplexy,  cerebral  tumor,  fatty  degeneration  of  the 
heart,  uremia,  and  similar  conditions. 

Dyspnea  may  be  constant  or  paroxysmal.  Constant  dyspnea  is 
always  due  to  a  persistence  of  its  cause.  Paroxysmal  dyspnea  is 
seen  in  asthma  and  cardiac  affections.  It  may  follow  exertion  in 
various  central  or  reflex  conditions.     It  is  most  marked  at  night. 

Cough  may  be  brought  about  by  reflex  irritation,  hysteria,  or 
direct  irritation  as  the  result  of  the  inhalation  of  irritant  vapors  or 
dust,  or  the  presence  of  foreign  bodies;  but  is  usually  due  to  inflam- 
matory conditions  of  the  pharynx,  larynx,  trachea,  bronchi,  or  lungs. 
In  the  early  stages  of  inflammation  of  any  portion  of  the  respiratory 
tract,  and  when  excited  reflexly,  it  occurs  without  expectoration  and 
is  termed  dry  cough.  With  the  occurrence  of  exudation  and  out- 
pouring of  serum,  blood,  etc.,  the  cough  is  attended  by  expectoration 
and  is  called  moist  cough.  Laryngeal  conditions,  whooping  cough, 
hysteria,  and  recurrent  laryngeal  nerve  irritation  are  attended  by  a 
cough  having  a  metallic  ringing  intonation.  This  is  laryngeal  or 
croupy  cough. 

Sputxim  may  vary  in  its  several  characteristics  according  to  the 
morbid  condition  present.  Mucoid  sputum  is  glairy,  clear,  and  tough 
30 


466  GENERAL    SYMPTOMATOLOGY 

and  contains  considerable  mucin.  It  may  be  observed  in  health  but 
occurs  with  great  frequency  in  the  early  stages  of  acute  bronchitis, 
pneumonia,  and  phthisis,  in  asthma,  and  in  pulmonary  edema. 
Watery  or  serous  sputum  occurs  in  pulmonary  edema  and  is  frothy 
in  character.  Muco-purulent  sputum  is  made  up  of  varying  propor- 
tions of  mucus  and  pus.  It  is  encountered  usually  in  subacute  and 
chronic  bronchitis,  pneumonia  in  the  stage  of  resolution,  and  phthisis. 
Purulent  sputum  is  that  which  is  made  up  almost  entirely  of  pus. 
This  is  a  rare  condition  and  occurs  in  abscess  of  the  lung,  or  adjacent 
viscera  discharging  into  a  bronchus,  tuberculous  cavities,  bronchiec- 
tasis, and  empyema.  Nummular  sputum  is  that  variety  which 
occurs  in  round,  flat  disks  which  sink  when  placed  in  water;  when 
spherical  it  is  termed  globular  sputum.  It  accompanies  advanced 
tuberculosis  and  bronchiectasis.  Fetid  sputum  is  that  which  when 
allowed  to  rest  undisturbed  separates  into  three  distinct  layers; 
the  upper  layer  being  composed  of  a  frothy,  watery  material;  the 
middle  layer  being  made  up  of  a  greenish  mucoid  substance ;  and  the 
bottom  layer  consisting  of  pus  and  debris.  It  is  a  symptom  of 
gangrene  of  the  lung,  bronchiectasis,  and  advanced  cavity  formation. 
Fibrous  sputum  contains  many  fibrous  shreds  and  may  be  seen  in 
the  various  inflammations  attended  with  fibrin  formation  as  fibrinous 
bronchitis,  diphtheria,  etc.  The  rusty  sputum  is  a  form  encountered 
in  lobar  pneumonia,  of  which  it  is  characteristic.  It  is  due  to  the 
admixture  of  a  small  quantity  of  bright  fresh  blood  with  the  thick 
tenacious  mucus  present.  When  the  blood  is  retained  in  the  vesicles 
and  bronchioles  it  becomes  altered  and  forms  the  prune-juice  sputum. 
In  gangrene,  cancer,  and  low  forms  of  croupous  pneumonia  it  may 
be  observed.  A  further  degeneration  of  the  blood  in  the  lungs  as 
in  malignant  disease  gives  rise  to  the  production  of  currant-jelly 
sputum.  The  sputum  observed  in  hepatic  abscess  contains  blood, 
pus,  bile  elements,  and  amebae,  and  is  called  reddish-brown  sputum. 

The  Microscopic  Exainination  of  the  Sputiun. — Blood  corpuscles 
and  alveolar  cells  are  present  in  the  sputum  and  may  be  detected 
by  the  aid  of  the  microscope  with  or  without  staining. 

Elastic  fibers  in  the  sputum  are  of  great  importance,  as  their 
presence  signifies  destruction  of  tissue  somewhere  in  the  respiratory 
tract..  They  are  found  in  phthisis,  gangrene,  and  bronchiectasis. 
They  are  usually  detected  in  the  sediment  that  is  formed  after 
boiling  equal  parts  of  the  sputum  with  a  10  per  cent,  solution  of 
caustic  potash.     The  elastic  tissue  remains  intact  in  the  sediment. 


GENERAL   SYMPTOMATOLOGY 


467 


A  B 

F  I  G.  ^  56. — C  u  r  s  c  h- 

mann's^spirals.  A,  un- 
magnified;  B,  magnified. 
{Greene's  Diagnosis.) 


Resort  to  the  microscope  will  enable  the  examiner  to  detect  the 
individual  jfibers. 

Connective  tissue  and  cartilage  may  in  very  rare  instances  be  present 
in  the  sputum  and  are  of  grave  significance.  The  former  may 
accompany  pulmonary  abscess  or  gangrene, 
while  the  latter  attends  laryngeal  ulceration. 
Curschmann's  spirals  (mucin  spirals)  are 
found  in  the  sputum  in  bronchial  asthma  and 
occasionally  in  pneumonia,  capillary  bronchitis, 
and  chronic  pulmonary  tuberculosis.  They  are 
made  up  of  spirally  arranged  mucin,  more  or 
less  twisted,  together  with  epithelium  and 
Charcot-Leyden  crystals,  and  represent  molds 
of  the  finer  bronchioles.  In  section,  they  stain 
blue  with  Weigert's  fibrin  method. 

Crystals. — Charcot-Leyden  crystals  are  colorless,  octahedral,  sharply 
pointed  crystals  resembling  grains  of  sand.  They  are  soluble  in 
warm  water,  alkalies,  acetic  acid,  and  the  mineral  acids.  They  are 
particularly  abundant  in  bronchial  asthma,  but  may  at  times  be 
detected  in  the  sputum  of  acute  and  chronic  bronchitis  and  tubercu- 
losis, in  leukemic  blood,  in  semen,  and  in  the  feces.  Cholesterin 
crystals  occur  in  the  sputum  in  tuberculosis,  abscess  of  the  lung, 
and  liver  abscess,  discharging  through  a  bronchus.  They  appear 
as  thin,  rhombic  plates,  with  irregular  corners.  Crystals  of  the  fatty 
acids,  particularly  of  margaric  acid,  are  found  in  purulent  pulmonary 
conditions  such  as  gangrene,  bronchiectasis,  etc.  They  appear  as 
long,  thin  needles,  occurring  singly  or  in  bundles,  and  not  unlike 
elastic  fibers.  Hematoid  crystals  appear  under 
the  microscope  as  small  rhomboid  prisms  or 
needles,  or  as  free  pigment  particles  of  a  brown- 
ish yellow  or  ruby-red  color.  They  occur  in 
the  sputum  in  pulmonary  hemorrhage,  abscess, 
cancer,  gangrene,  and  tuberculosis. 

Method  for  the  Detection  of  Tubercle  Bacilli. — 
The  significance  of  the  presence  of  tubercle  bacilli 
in  the  sputum  is  undoubted — they  indicate  the 
presence  of  tuberculosis;  but  inability  to  find 
them  does  not  necessarily  imply  an  absence  of 
the  disease.  The  bacillus  is  a  straight  or  slightly  curved,  non-motile 
organism,  varying  in  length  from  2  to  5  microns.     Staining  is  neces- 


FiG.  57. — Tubercle 
bacilli  in  sputum. 
{From  Greene's  Medical 
Diagnosis.) 


4.68  ACUTE    NASAL    CATARRH 

sary  for  its  detection.  When  stained,  it  often  presents  a  beaded 
appearance,  due  to  the  spores.  To  examine  the  sputum  for  tubercle 
bacilli  a  small  caseous  particle  should  be  selected  and  spread  out  in  a 
very  thin  layer  on  a  cover-glass  or  slide.  It  is  allowed  to  dry  in  the  air 
or  by  passing  it  through  the  flame  of  a  Bunsen  burner  (smeared  side 
up)  three  times.  Ziehl's  carbolfuchsin  stain  (fuchsin  i;  alcohol  lo; 
5  p§r  cent,  aqueous  solution  of  carbolic  acid  90)  is  then  poured  gener- 
ously over  the  entire  specimen;  which  should  then  be  held  a  short 
distance  above  the  flame  for  a  few  seconds  until  steam  is  formed. 
The  slide  or  cover-glass  should  then  be  thoroughly  washed  in  running 
water  to  remove  the  excess  of  the  stain.  Gabbet's  solution  (methyl- 
ene-blue  2;  sulphuric  acid  25;  water  75)  is  then  employed  to  counter- 
stain  the  preparation,  for  which  a  period  of  about  thirty  seconds  is 
required.  The  excess  of  this  stain  is  also  removed  by  running  water, 
after  which  the  specimen  is  dried  and  mounted  in  Canada  balsam. 
When  viewed  through  a  3i^2  oil  immersion  lens,  the  tubercle  bacilli 
appear  as  red  rods  on  a  blue  background. 

DISEASES  OF  THE  NASAL  PASSAGES 

ACUTE  NASAL  CATARRH 

Synonyms. — ^Acute  rhinitis;  acute  coryza;  ''cold  in  the  head." 
Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  (pituitary  or  Schneiderian  membrane)  lining  the  nose 
and  the  cavities  communicating  with  it;  characterized  by  feverishness, 
feeling  of  fullness  and  discomfort  in  the  head,  and  attended  with 
discharges  of  fluid,  watery,  mucous,  or  muco-purulent  in  character. 
Causes. — Atmospheric  changes,  exposure  of  the  neck  to  a  draught 
of  cold  air,  or  of  the  ankles  to  cold  and  dampness,  changing  from  a 
warm  to  a  cold  atmosphere  suddenly,  inhalation  of  irritant  gases 
and  vapors,  dust,  and  powders,  such  as  ipecac  and  tobacco,  are  the 
most  common  causes.  The  scrofulous  taint  and  the  rheumatic 
diathesis  seem  to  render  the  mucous  membrane  susceptible  to  fre- 
quent attacks.  Acute  coryza  is  often  present  in  the  initial  stage  of 
the  infectious  fevers,  such  as  measles,  influenza,  and  erysipelas. 
Syphilis,  and  potassium  iodide  in  large  doses  may  at  times  produce 
it.  Occasionally  the  affection  seems  to  be  contagious  in  character, 
and  epidemics  are  observed.  Various  organisms  have  been  found  in 
connection  with  this  disease. 


ACUTE  NASAL  CATARRH  469 

Pathology. — In  the  early  stage  there  is  hyperemia  of  the  mucous 
membrane,  attended  with  redness,  swelling,  and  deficient  secretion. 
This  tumefaction  is  partly  increased  by  an  edematous  infiltration, 
causing  a  quantity  of  colorless,  salty,  and  very  thin  liquid  to  flow 
from  the  nose.  The  secretion  soon  assumes  the  character  of  thick, 
tenacious  mucus  or  muco-pus  due  to  the  desquamation  of  the  epithe- 
lium of  the  nasal  mucous  membrane,  and  a  copious  generation  of 
young  cells,  the  hyperemia  and  the  swelling  of  the  membrane  dimin- 
ishing. The  respiratory  portions  of  the  nasal  fossae  are  more  mark- 
edly affected  than  are  the  olfactory.  Rarely,  and  then  in  new-born 
infants  and  those  affected  with  the  eruptive  fevers,  the  exudation 
in  the  nasal  passages  is  of  a  fibrinous  nature,  somewhat  similar  to 
that  observed  in  diphtheria. 

Symptoms. — "A  cold  in  the  head"  is  usually  preceded  by  a  feeling 
of  lassitude  or  weariness  and  more  or  less  frontal  headache;  then 
occur  irregular  chilly  sensations  in  the  back,  followed  by  more  or 
less  feverishness  and  an  uncomfortable  feeling  of  dryness  in  the 
nares,  with  a  strong  inclination  to  sneeze.  This  is  soon  followed  by  an 
abundant  watery  and  saline  discharge,  which  is  continually  drip- 
ping from  the  nostrils,  or  occasions  an  attack  of  sneezing  followed 
by  blowing  the  nose,  which  relieves  the  congested  and  swollen 
membrane  for  a  few  moments.  The  relief  is  only  temporary,  how- 
ever, the  fullness  of  the  head  and  difficult  obstructed  nasal  respira- 
tion rapidly  returning.  The  anterior  nares  are  red  and  inflamed, 
and  the  eyes  red  and  suffused  with  tears,  through  partial  or  entire 
closure  of  the  tear-ducts.  The  discharge  soon  assumes  a  purulent 
character.  The  voice  has  a  peculiar  tone,  rather  nasal  and  muffled 
in  character.  Within  a  few  days  the  swelling  subsides  and  secretion 
lessens,  health  being  restored  in  about  ten  days  from  the  beginning 
of  the  attack.  When  the  attack  has  almost  terminated,  hard 
crusts  may  form  within  the  nostrils  (either  on  the  septum  or  turbin- 
ated bones)  which  are  with  difficulty  expelled  by  blowing  the 
nose. 

Complications. — Repeated  blowing  of  the  nose  and  constant 
irritation  by  the  discharges  often  causes  swelling  of  the  upper  lip. 
The  catarrhal  inflammation  may  extend  to  the  ethmoid  or  sphenoid 
cavities,  or  the  frontal  sinus,  causing  increased  and  severe  frontal 
headache,  or  to  the  antrum  of  Highmore,  causing  tenderness  over 
one  or  both  cheeks.  Extension  to  the  Eustachian  tube  and  middle 
ear  will  cause  temporary  deafness  and  extension  to  the  pharynx  or 


47©  ACUTE  NASAL  CATARRH 

larynx  will  give  rise  to  cough.  Conjunctivitis  may  also  occur  as 
the  result  of  extension  through  the  nasal  duct. 

Prognosis. — If  the  appropriate  treatment  is  instituted  promptly, 
mild  cases  will  terminate  favorably  in  about  a  week,  and  severe 
cases  in  two  or  more  weeks.  Neglected  cases  tend  to  become  chronic. 
In  very  young  infants,  if  the  catarrh  is  not  rapidly  relieved,  loss  of 
flesh  and  strength  will  follow  on  account  of  the  inability  to  nurse. 

Treatment. — When  due  to  atmospheric  causes  the  early  adminis- 
tration of  quinine  sulphate,  gr.  x  to  xv  (0.6  to  i  gm.),  with  morphine 
sulphate,  gr.  >^  (0.016  gm.),  or  Dover's  powder,  gr.  v  (0.3  gm.), 
repeated  in  two  hours,  will  often  serve  to  abort  an  attack.  A  hot 
foot-bath  or  full  bath,  together  with  rest  and  purgation  by  saline 
laxatives,  aids  this  abortive  treatment  materially.  Sodium  bicarbon" 
ate,  gr.  xx  (1.3  gm.),  in  two  fluidounces  (60  c.c.)  of  hot  water  every 
half  hour  for  3  doses  (the  fourth  dose  to  be  given  after  an  hour's 
interval)  has  been  recommended  as  an  efficient  abortive  treatment. 
The  following  used  at  the  very  onset  has  often  proved  successful: 

I^.     Aluminis 

Bismuth  subcarb. 

Pulv.  camphorse aa  gr.  xx  aa  i  .3    gm. 

Morphinae  hydrochlor gr.  ij  0.13  gm. 

M.     Ft.  chart.  No.  xx. 

S. — Insufflate  one  powder  in  each  nostril  after  clearing  the 
nose. 

If  the  attack  has  already  developed,  relief  is  soon  afforded  by  the 
use  of  tincture  of  belladonna,  TTLij  (0.12  c.c),  every  hour  until  6 
doses  are  taken,  after  which  i  drop  every  two  or  three  hours  until 
the  physiological  effects  of  the  drug  are  manifest.  If  much  fever  is 
present  tincture  of  aconite,  TTtv  (0.3  c.c),  may  be  added.  Camphor 
in  full  doses  at  the  onset  is  also  of  value.  Sajous  recommends  the 
following : 

I^.     Ammonii  chloridi gr.  xl  2.6  gm. 

Tinct.  opii lUxxx  2  .0  c.c. 

Sacch.  alb 5j  4.0  gm. 

Aq.  camphorse f Sj  30.0  c.c. 

M.  S. — One  teaspoonful  in  water  every  hour  or  two. 

The  following  has  also  been  recommended  as  "the  best  prescription 
for  the  treatment  of  common  cold  or  nasal  catarrh:" 


CHRONIC   NASAL   CATARRH  47 1 

I^.     Sodii  salicylatis gr.  Ixxx  5 .  o  gm. 

Spt.  ammoniae  aromatici . . .   f  5  iv  16.0  gm. 

Tinct.  belladonnas lUxl  2 . 6  c.c. 

Aq.  chloroformi. . .  .q.  s.  ad  f  Sviij  240.0  c.c. 

M.  S. — One  tablespoonful  every  four  hours. 

Attacks  of  acute  rhinitis,  unattended  by  febrile  reaction,  may 
generally  be  lessened  or  promptly  aborted  by  spraying  the  nares 
with  a  4  per  cent,  solution  of  cocaine  hydrochloride  or  adrenalin 
chloride  (i  to  5000).  The  danger  of  cocaine  habit  should  always 
be  kept  in  mind  when  employing  the  former. 

Acute  coryza  in  nursing  infants  may  be  controlled  by  the  insuffla- 
tion into  the  nose  of  finely  powdered  white  sugar,  or  equal  parts  of 
powdered  white  sugar  and  powdered  camphor,  or  powdered  sugar, 
3iv  (15  gm.),  powdered  camphor,  5iv  (15  gm.),  and  tannic  acid, 
gr.  xl  (2.6  gm.)'. 

Most  cases  of  coryza  in  very  young  children  are  usually  of  syph- 
ilitic origin  and  require  specific  treatment.  Symptomatic  coryza 
necessitates  no  special  treatment.  In  all  cases  cleansing  of  the  nose 
with  alkaline  solutions,  especially  Dobell's  solution,  will  be  of  value. 

CHRONIC  NASAL  CATARRH 

Synon3mis. — Chronic  rhinitis;  chronic  coryza;  ozena. 

Definition. — A  chronic  inflammation  of  the  mucous  membrane 
lining  the  nasal  passages,  with  more  or  less  alteration  of  structure; 
characterized  by  a  sensation  of  fullness  in  the  nares,  increased  secre- 
tion, and  a  perversion  of  the  senses  of  smell  and  hearing. 

Causes. — It  may  occur  as  the  result  of  repeated  attacks  of  the 
acute  variety;  inhalation  of  irritating  vapors  and  dust;  syphilis 
and  scrofula. 

Pathological  Anatomy. — Two  forms  are  recognized:  (i)  Hyper- 
trophic rhinitis,  in  which  the  mucous  membrane  of  the  nares  is 
thickened,  of  a  dark  red  sometimes  grayish  color,  the  superficial 
veins  are  dilated  and  varicose,  often  forming  polypoid  enlargements. 
(2)  Atrophic  rhinitis.  In  many  cases  there  is  ulceration  of  the  struc- 
ture, with  more  or  less  loss  of  substance;  the  secretion  is  thick, 
tough,  of  a  greenish  character,  and  often  very  fetid;  large  collections 
of  dried  mucus  are  often  formed  upon  the  turbinated  bones  and 
septum. 


472  CHRONIC   NASAL   CATARRH 

Symptoms. — There  is  a  feeling  of  fullness  in  the  nose,  with  in- 
creased secretion  of  thick  and  greenish  muco -purulent  material 
which,  dropping  posteriorly  into  the  pharynx,  causes  paroxysms  of 
''hawking,"  most  marked  in  the  morning  immediately  after  rising. 
The  sense  of  smell  is  more  or  less  impaired  and  in  many  instances 
entirely  abolished;  hearing  is  diminished  in  many  instances  due  to 
extension  of  the  inflammation  to  the  Eustachian  tube.  The  voice 
has  a  peculiar  nasal  intonation.  Mouth-breathing  is  common  on 
account  of  the  nasal  obstruction.  There  is  an  almost  constant  dull 
frontal  headache,  associated  with  a  feeling  of  weight,  indicating 
extension  of  the  disease  to  the  infundibulum  and  frontal  sinus. 
When  the  affection  extends  to  the  nasal  duct,  lacrimation  and  con- 
geslfion  of  the  conjunctiva  result. 

In  the  atrophic  form,  there  is  marked  shrinkage  of  the  mucous 
membrane,  which  is  pale  and  dry.  The  secretion  is  thick  and  green- 
ish and  dries  within  the  nasal  chambers,  forming  large,  offensive 
crusts,  the  odor  of  which  is  characteristic.  Ulceration  is  not  un- 
common and  necrosis  of  the  bones  may  occur.  This  form  of  the 
affection  is  termed  ozena. 

In  all  varieties,  sudden  changes  in  the  atmosphere  are  liable  to 
give  rise  to  acute  exacerbations,  which  invariably  lead  to  exaggera- 
tion of  all  the  symptoms. 

Diagnosis. — While  the  symptoms  are  suggestive  of  the  varieties 
of  this  affection,  the  diagnosis  can  only  be  made  positively  by  rhino- 
scopic  examination. 

Prognosis. — Permanent  cure  is  seldom  obtained;  the  disease 
being  so  decidedly  chronic  and  obstinate,  the  treatment  is  of  necessity 
protracted,  and  the  majority  of  patients  tire  of  it  before  a  complete 
cure  is  effected.  In  ozena,  the  prognosis  as  to  cure  is  unfavorable, 
but  much  can  be  done  to  relieve  the  symptoms  by  appropriate 
treatment.  Unfortunately,  by  reason  of  impairment  of  the  sense  of 
smell,  the  patient  is  unable  to  detect  the  offensive  odor  the  crusts 
produce,  and  neglects  treatment. 

Treatment. — In  the  presence  of  evidences  of  syphilis,  tuberculosis, 
rheumatism,  etc.,  constitutional  treatment  should  be  prescribed  in 
addition  to  local  measures;  In  all  cases,  the  general  health  should 
receive  any  necessary  treatment. 

Cleanliness  of  the  nasal  passages  is  of  the  utmost  importance 
and  is  best  effected  by  the  post-nasal  syringe,  with  either  simple  or 
medicated  tepid  waters,  or  a  cleansing  solution,  such  as  Dobell's: 


CHRONIC    NASAL   CATARRH  473 

I^.     Acidi  carbolic! gr.  j  o. 065  gm. 

Sodii  bicarbonat., 

Sodii  borat aa  gr.  v  aa  o .  3      gm. 

Glycerini f 5]  40      c.c. 

Aquas fBj  30.0      c.c. 

M,  S. — Use  as  a  spray  or  with  a  proper  syringe. 

Or,  the  following  combination  of  Sajous — 

I^.     Sodii  bicarb., 

Sodii  bibor aa  gr.  viij  aa     o.  52  gm. 

Fluidextracti  pinus  canad. .   T([xv  i.o    c.c. 

Glycerini f  5 ij  8.0    c.c. 

Aquae q.  s.  ad  f  5iv  q.  s.  ad  120.0    c.c. 

M.  S. — Apply  with  atomizer  three  or  four  times  daily. 

After  which,   decided  benefit  follows  the  use  of  the  following: 

I^.     Pulv.  sanguinarias 5j  4-0  gm. 

Acid,  tannici gr.  v  0.3  gm. 

Pulv.  camphorae 5j  4-0  gm. 

Bismuth,  subnit 5ij  8.0  gm. 

M.  S. — To  be  used  by  insufflation  or  as  a  snuff  every  three 
or  four  hours. 

I^.     Ammonii  chloridi 5j  4  gJ^- 

Glycerini f  5ij  8  c.c. 

Fluidextracti  pinus  canad. .   f  §  j  30  c.c. 

Aquae  destil q.  s.  ad  f  Bij    q.    s.    ad    60  c.c. 

M.   S. — Five  or   10  drops,   dropped  into  each  nostril  two  or 

three  times  a  day,  or  applied  with  a  camel's-hair  brush. 

Or  the  following  pleasant  mixture  may  be  applied  to  each  nostril : 

I^.     Tinct.  benzoin f5iv  15.0  c.c. 

Tinct.  guaiaci f  3j  4-0  c.c. 

Chloroformi lUx  o .  6  c.c. 

Tinct.  myrrh f  5ss  2.0  c.c. 

01.  amygd T([v  0.3  c.c. 

M.  S. — A  few  drops  in  each  nostril  once  a  day. 

Frequently  the  mucous  membrane  becomes  greatly  hypertrophied 
and  requires  the  use  of  the  galvanocautery  or  caustics  to  remove  the 
obstruction.  Polyps  may  also  form  and  should  be  removed  by  the 
snare.     In  atrophic  rhinitis  or  ozena  difficulty  is  often  encountered 


474  ACUTE  CATARRHAL  LARYNGITIS' 

in  removing  the  crusts  before  making  any  local  application.  This 
may  be  overcome  by  the  use  of  peroxide  of  hydrogen  or  ordinary 
coal-oil  and  generous  douching  with  an  alkaline  solution.  Oily 
sprays,  such  as  liquid  vaselin,  albolene,  with  or  without  the  addi- 
tion of  menthol,  eucalyptol,  or  thymol,  may  then  be  employed. 
Boroglycerin  is  also  of  great  value. 

DISEASES  OF  THE  LARYNX 

ACUTE  CATARRHAL  LARYNGITIS 

Synonyms. — Catarrhal  laryngitis;  "sore  throat." 

Definition. — An  acute  catarrhal  inflammation  of  the  mucous 
membrane  of  the  larynx;  characterized  by  feverishness,  diminished 
or  suppressed  voice,  painful  deglutition,  and  more  or  less  difficulty 
of  respiration. 

Causes. — Atmospheric  changes,  cold  draughts  of  air  directly 
inhaled,  or  undue  exposure  of  any  or  ail  parts  of  the  body  to  the  same, 
cold  and  wet  feet,  inhalation  of  dust  or  irritating  vapors,  such  as 
gases,  smoke,  ammonia,  etc.,  prolonged  efforts  at  singing  or  speaking 
in  public,  especially  when  under  difficulties,  impacted  foreign  body, 
and  infectious  fevers  are  the  most  common  causes.  It  may  also  be 
associated  with  catarrh  of  the  nose,  pharynx,  trachea,  or  bronchi. 
In  children  it  may  be  due  to  violent  fits  of  crying.  Some  people  have 
a  predisposition  to  catarrhal  laryngitis. 

Pathological  Anatomy. — The  mucous  membrane  is  congested  and 
swollen,  and  the  secretion  greatly  diminished.  In  many  cases  only 
portions  of  the  laryngeal  mucous  membrane  are  involved.  The 
inflamed  membrane  returns  to  its  normal  condition  very  shortly, 
and  the  secretion  is  then  increased. 

Symptoms. — The  attack  begins  rather  suddenly  with  a  feeling  of 
dryness,  rawness,  and  tickling,  referred  to  the  larynx  with  the  sensa- 
tion of  the  presence  of  a  foreign  body  in  the  throat,  and  with  hoarse- 
ness and  a  disposition  to  cough.  Deglutition  causes  pain  by  the 
upward  movement  of  the  larynx  and  by  the  pressure  of  the  food  on 
the  larynx  as  it  passes  along  the  gullet.  Attempts  at  speaking  are 
attended  with  more  or  less  distress  and  the  larynx  is  tender  on  pres- 
sure. Coughing,  of  a  noisy,  harsh,  hoarse,  or  toneless  character  is 
present  from  the  onset,  and  is  attended  by  a  sensation  of  scratching 
in  the  larynx.     The  first  day  or  two  there  is  scanty  expectoration, 


ACUTE    CATARRHAL   LARYNGITIS  475 

but  in  a  short  time  the  secretion  is  increased,  giving  the  cough  a  loose 
character.  In  the  early  stages  the  sputa  may  be  slightly  streaked 
with  blood.  Rarely  a  hemorrhage  occurs  from  the  mucous  membrane 
of  the  larynx.  The  voice  is  at  first  decidedly  hoarse,  soon  followed 
by  complete  aphonia.  The  respiration  is  but  slightly,  if  at  all, 
affected  in  adults,  except  when  there  is  marked  edema.  There  may 
be  more  or  less  febrile  reaction.  In  children  the  onset  is  attended 
with  fever,  white  coated  tongue,  frequent,  tense  pulse,  hot  skin  and 
flushed  face,  embarrassed  respiration,  the  voice  hoarse  and  whisper- 
ing, with  harsh,  ringing,  croupy  cough  and  great  restlessness.  During 
the  night  the  child  is  subject  to  suffocative  attacks  (laryngismus 
stridulus).  Similar  paroxysms  may  also  occur  in  highly  sensitive 
adults. 

Laryngoscopic  Appearances. — These  vary  with  the  severity  of 
the  attack  and  the  stage  of  the  inspection.  In  mild  cases,  at  an 
early  period,  the  mucous  membrane  presents  a  bright  red  appear- 
ance. Severe  cases  present,  in  addition  to  the  bright  redness, 
swelling  of  the  mucous  membrane  to  such  an  extent  at  times 
as  to  conceal  the  vocal  cords,  they  appearing  only  as  slender  threads 
of  a  reddish  tint.  At  times  the  mucous  membrane  presents  the 
appearance  of  erosions  or  ulcerations,  due  to  the  desquamation  of 
the  epithelium. 

Prognosis. — Simple  catarrhal  laryngitis  never  terminates  fatally 
and  runs  its  course  usually  in  one  week,  but  may  be  prolonged  for 
two  or  three  weeks  in  severe  cases.  When  edema  is  present  in  addi- 
tion, there  is  always  danger  from  asphyxia. 

Treatm.ent. — The  patient  should  be  confined  to  an  apartment  of 
uniform  temperature,  the  air  being  kept  moist  by  the  vapor  of  boiling 
water.  Attempts  to  use  the  voice  should  be  discountenanced.  At 
the  very  beginning  of  an  attack  the  feet  should  be  placed  in  a  hot 
mustard  foot-bath  and  either  a  saline  or  mercurial  purgative  should 
be  administered.  Prompt  action  of  the  skin  at  this  stage  will  fre- 
quently aid  in  shortening  the  attack.  For  this  purpose  Dover's 
powder,  gr.  iij  (0.2  gm.),  combined  with  potassium  nitrate,  gr.  iij 
(0.2  gm,),  should  be  administered  every  three  or  four  hours.  If 
there  is  much  febrile  reaction,  benefit  will  be  obtained  from  the  use  of 
tincture  of  aconite,  Tflv  (0.3  c.c),  every  half -hour  until  5  doses  are 
taken,  after  which  it  should  be  given  every  hour  or  two,  combined 
with  tincture  of  opium,  TTlj  to  v  (0.06  to  0,3  c.c).  Diaphoresis  is 
also  of  value  and  may  be  obtained  by  the  administration  of  antimony 


476  EDEMATOUS    LARYNGITIS 

and  potassium  tartrate,  gr.  Ho  to  }io  (0.002  to  0.003  gm.),  every 
hour,  or  by  the  hypodermic  injection  of  pilocarpine  hydrochloride, 
gr.   }i   (0.022   gm.). 

For  children,  several  doses  of  the  following  should  be  given  a 
couple  of  hours  apart,  until  the  bowels  are  freely  moved: 

I^.     Hydrargyri  chloridi  mitis.  .   gr.  }4  0.008  gm. 

Pulvis  ipecacuanhae gr.  3^  0.008  gm. 

Sacch.  lactis gr.  ij  0.13    gm. 

M.  S. — One  dose. 

To  be  followed  by — 

'^.     Potassii  citrat 5iv  i5-0  gm. 

Tinct.  aconiti lUxv  i.o  c.c. 

Tinct.  opii  camphorat f5ij   to  iv  8  to   15  c.c. 

Syr.  scillae f5ij  8.0  c.c. 

Syr.  tolu q.  s.  ad  f  giij  q.s.  ad    90.0  c.c. 

M.  S. — One  teaspoonful  every  two  hours. 

If  a  tendency  to  spasm  of  the  glottis  obtains,  full  doses  of  the  bro- 
mides should  be  administered  at  once. 

Inhalations  from  the  onset  are  not  only  soothing,  but  curative,  in 
their  actions.     The  following  is  recommended: 

I^.     Tinct.  benzoin  comp f  5j  to  ij  4  to  8  c.c. 

Aquse  bull Oj  480  c.c. 

M.  S. — Inhale  hourly. 

The  local  application  of  cocaine  is  of  great  benefit.  A  hot  pack 
should  also  be  kept  constantly  wrapped  about  the  throat,  and  if  its 
application  is  preceded  by  the  temporary  use  of  a  weak  mustard 
plaster,  the  relief  afforded  is  more  rapidly  obtained. 

Attacks  of  acute  laryngitis  following  efforts  at  singing  or  speaking 
in  public  are  wonderfully  benefited  by  the  use  of  dilute  nitric  acid, 
TUij  to  V  (0.12  to  0.3  c.c),  every  hour;  or  atropine  sulphate,  gr. 
3^00  (0.00022  gm.),  every  hour  for  several  doses. 

The  onset  of  edema  calls  for  cold  applications,  scarification, 
astringent   applications,   and,   if  asphyxia  threatens,   tracheotomy. 

EDEMATOUS  LARYNGITIS 

Synonym. — Edema  of  the  glottis. 

Definition. — An   acute  inflammation   of  the   mucous   membrane 


EDEMATOUS    LARYNGITIS  477 

of  the  larynx  and  that  about  the  glottis,  'with  an  infiltration  of  the 
areolar  tissues  by  a  serous,  sero-purulent  or  purulent  fluid ;  character- 
ized by  obstructed  or  stridulous  breathing  and  dysphonia  or 
aphonia. 

Causes. — It  may  occur  in  the  course  of  acute  laryngitis,  suppura- 
tion in  or  about  the  throat  or  tonsils,  facial  erysipelas,  scarlatina, 
small-pox,  diphtheria,  Bright's  disease,  or  urticaria.  Burns,  scalds, 
swallowing  of  caustic  substances,  and  ulcerative  affections  such  as 
tuberculosis  and  syphilis  may  produce  it.  It  is  rare  in  children,  most 
cases  occurring  in  men  between  the  ages  of  twenty  and  thirty-five 
years. 

Pathological  Anatomy. — Infiltration  into  the  loose  connective 
tissue  of  the  ary-epiglottic  folds,  the  glosso-epiglottic  ligament,  the 
base  of  the  epiglottis,  and  the  interarytenoid  space  is  the  principal 
change.  If  the  true  vocal  cords  are  inflamed,  their  color  changes, 
and  instead  of  appearing  white,  glistening  and  brilliant,  they  are 
dull,  grayish-red,  or  violet-red  in  patches.  If  the  swelling  be  the 
result  of  purulent  infiltration,  the  parts  present  a  deeply  congested 
color,  with  here  and  there  spots  of  a  yellowish  hue.  Serous  infil- 
tration, sufficient  to  cause  fatal  edema,  disappears  with  death,  leaving 
but  slight  traces  to  account  for  the  formidable  symptoms. 

Symptoms. — The  onset  is  much  the  same  as  a  simple  catarrhal 
laryngitis  with  a  gradually  increasing  impediment  to  the  respiration. 
The  patient  experiences  the  sensation  of  a  foreign  body  in  the  throat, 
and  after  a  short  time  difficulty  of  breathing,  which  ultimately 
threatens  suffocation.  The  deglutition  is  rendered  difficult  owing  to 
the  swelling  of  the  epiglottis;  the  voice,  at  first  muffled,  gradually  be- 
comes weaker  and  weaker,  until  finally  it  is  almost  extinct ;  the  cough 
at  first  is  dry  and  harsh,  but  as  the  infiltration  increases  it  becomes 
stridulous  and  suppressed;  there  is  no  expectoration,  except  after 
great  effort  to  clear  the  throat,  when  a  little  frothy  mucus  is  raised. 
The  difficulty  of  respiration,  as  the  disease  progresses,  becomes 
greater  and  greater,  and  the  paroxysms  of  impending  suffocation 
more  frequent.  The  inspiration  is  accompanied  by  a  whistling 
sound  characteristic  of  the  narrow  condition  of  the  glottis;  the 
patient  sits  up  in  bed,  his  mouth  open,  gasping  for  breath,  his  eyes 
protruding,  the  whole  body  trembling  with  intense  convulsive  move- 
ments, and  after  a  time  a  general  cyanosis  commences,  the  face 
assuming  a  bluish  hue,  all  these  symptoms  continuing  for  a  few  mo- 
ments, when  slight  relief  occurs,  to  be  again  followed  by  another 


478  EDEMATOUS    LARYNGITIS 

paroxysm,  in  one  of  which,  if  nature  or  art  does  not  afford  prompt 
relief,  death  occurs  from  asphyxia. 

A  physical  examination  of  the  parts  may  be  made  by  gently  passing 
the  finger  into  the  throat,  when  the  epiglottis  may  be  felt  very 
much  thickened,  and  the  ary-epiglottic  folds  may  have  attained  such 
tumefaction  as  to  convey  to  the  finger  an  impression  similar  to  that 
which  is  given  by  touching  the  tonsils. 

Laryngoscopic  Appearance. — The  mucous  membrane  has  a  bright 
red  appearance.  The  epiglottis  has  the  appearance  of  a  semitrans- 
parent,  roll-like  body,  or  it  is  often  merely  erect  and  tense.  It  is 
this  condition  of  the  epiglottis  which  explains  the  pain  and  difficulty 
in  deglutition.     Rarely  the  vocal  cords  are  infiltrated. 

Diagnosis. — Any  disease  which  gives  rise  to  dyspnea  may  simulate 
edematous  laryngitis,  but  the  history  of  the  case,  together  with  a 
laryngoscopic  examination,  will  generally  furnish  conclusive  evi- 
dence of  the  nature  of  the  malady. 

Prognosis. — The  outlook  is  unfavorable;  about  one-half  of  the 
cases  terminate  fatally.  If  early  and  vigorous  treatment  be  insti- 
tuted recovery  is  possible,  but  without  it  asphyxia  and  death  are 
the  inevitable  results.  Even  after  the  local  obstruction  has  been 
removed,  the  patient  is  liable  to  perish  subsequently  from  exhaustion, 
blood-poisoning,  or  pulmonary  complications.  The  duration  varies 
from  a  few  hours  to  several  days. 

Treatment. — Prompt  local  treatment  is  necessary  to  relieve  the 
obstruction.  Leeches  placed  externally  over  the  larynx  may  be  of 
value  in  reducing  the  edema  in  mild  cases.  The  persistent  use  of 
ice-pellets  early  in  the  attack,  swallowed  or  held  far  back  in  the  mouth 
until  dissolved,  is  recommended  by  Niemeyer;  or  the  Leiter  coil  may 
be  used.  The  hypodermic  injection  of  pilocarpine  hydrochloride, 
gr.  3^  (0.022  gm.),  until  free  salivation  and  diaphoresis  are  produced, 
is  of  great  value,  care  being  taken  to  avoid  cardiac  depression. 

Relief  may  be  afforded  in  the  early  stage  by  scarification  of  the 
edematous  tissues,  guiding  the  instrument  by  the  index  finger  of 
the  opposite  hand.  If  the  various  measures  already  mentioned  fail, 
tracheotomy  or  intubation  is  indicated. 

In  all  cases  food  and  stimulants  should  be  administered,  preferably 
by  the  rectum,  as  swallowing  is  difficult  and  serves  to  aggravate  the 
condition.  If  the  infiltration  becomes  purulent,  quinine  sulphate, 
gr.  V  (0.3  gm.)  every  four  hours  is  indicated  in  addition. 


SPASMODIC    LARYNGITIS  479 

SPASMODIC    LARYNGITIS 

Synonyms. — Spasmodic    croup;    false    croup;    catarrhal    croup. 

Definition. — A  catarrhal  inflammation  of  the  mucous  membrane 
of  the  larynx,  associated  with  temporary  spasmodic  contraction  of 
the  glottis;  characterized  by  paroxysmal  coughing,  difficulty  of 
breathing,  and  attacks  of  threatening  suffocation. 

Causes. — Atmospheric  changes  or  "taking  cold,"  excesses  in 
eating  and  drinking,  excitement,  and  violent  emotion,  are  given 
as  causes. 

Pathological  Anatomy. — Congestion  of  the  mucous  membrane  of 
the  larynx,  with  slight  swelling  and  deficient  secretion,  are  the  only 
changes  that  have  thus  far  been  noted. 

Symptoms. — The  attack  occurs  chiefly  during  the  night,  the  child 
on  retiring  having  either  its  usual  health,  or  perhaps  being  a  little 
feverish.  After  several  hours  of  sleep  the  child  is  suddenly  awakened 
by  a  paroxysm  of  suffocation,  and  a  dry,  harsh,  ringing  cough. 
After  half  an  hour  or  an  hour  or  two  the  breathing  becomes  easier, 
and  the  cough  less  "croupy;"  the  skin  is  covered  with  more  or  less 
perspiration,  and  the  child  falls  asleep.  The  next  day  there  is  present 
cough  of  a  loose  character,  the  respiration  being  about  normal. 
If  no  treatment  be  instituted,  the  same  phenomena  occur  on  the 
second  night,  the  child  being  apparently  well  during  the  second  day, 
the  cough  being  less  in  amount;  phenomena  of  a  similar  character, 
but  of  much  less  severity,  are  present  the  third  night,  after  which 
the  disease  usually  disappears. 

Diagnosis. — The  history,  course,  and  absence  of  marked  constitu- 
tional disturbances  will  distinguish  this  affection  from  diphtheria; 
in  the  latter .  a  bacteriological  examination  will  show  the  Klebs- 
Loeffler  bacilli.  In  laryngismtis  stridulus,  there  is  a  history  of  rachitis, 
and  an  absence  of  catarrhal  symptoms. 

Prognosis. — Spasmodic  or  false  croup  always  terminates  favorably. 

Treatment. — During  th,e  paroxysm,  the  child  should  at  once  be 
placed  in  a  hot  bath  and  hot  or  cold  compresses  should  be  applied 
to  the  throat.  These  measures  should  be  preceded  or  followed  by 
the  administration  of  a  mild  emetic.  The  syrup  or  wine  of  ipecac, 
in  doses  of  5ss  to  3j  (2  to  4  c.c),  every  few  minutes  until  vomiting 
is  produced,  is  very  efficient.  Bartholow  recommends  turpeth 
mineral,  gr.  j  to  iij  (0.065  to  0.2  gm.);  DaCosta  suggests  the  cautious 
use  of  apomorphine  hydrochloride,  gr.  Ho  (0.006  gm.),  hypodermic- 


480  LARYNGISMUS    STRIDULUS 

ally.  The  late  Charles  D.  Meigs  always  used  powdered  alum  alone 
or  with  syrup  of  ipecac.  Powdered  alum  is  of  great  value  in  tea- 
spoonful  doses,  administered  in  honey  or  molasses  and  repeated  in 
fifteen  minutes,  until  vomiting  is  produced.  In  the  absence  of  these 
means  of  inducing  emesis,  irritation  of  the  fauces  b}?"  a  feather  or  by 
the  finger  will  bring  about  the  desired  result.  In  very  severe 
paroxysms  the  inhalation  of  chloroform  may  be  necessary. 

As  soon  as  the  paroxysm  has  been  broken,  a  laxative  should  be 
given.  Calomel,  gr.  ij  (0.13  gm.),  and  sodium  bicarbonate,  gr.  iij 
(0.2  gm.),  should  be  administered  and  followed  in  six  or  eight  hours 
by  a  dose  of  castor  oil  or  magnesia.  During  the  intervals  between 
the  paroxysms,  small  doses,  TTLv  to  x  (0.33  to  0.66  c.c),  of  the  syrup 
or  wine  of  ipecac,  or  the  following,  should  be  given: 

I^.     Tincturae  aconiti lUxxiv  i  .5  c.c. 

Syr.  ipecacuanhae f  5jss  6.0  c.c. 

Tincturae  opii  camphorat .  .   f5iij  12.0  c.c. 

Liq.  potassii  citratis  q.  s.  ad  f  Siij             ad  90.0  c.c. 
M.  S. — One  teaspoonful  every  hour  or  two. 

LARYNGISMUS  STRIDULUS 

Synonyms. — Spasm  of  the  glottis;  spasmodic  laryngitis;  thymic 
asthma;  tetany;  child-crowing. 

Definition. — A  spasm  of  the  muscles  of  the  larynx  innervated  by 
the  inferior  or  recurrent  laryngeal  nerves ;  characterized  by  a  sudden 
development  of  dyspnea  and  deficient  oxygenation  of  the  blood. 

Causes. — The  affection  is  most  common  in  young  children,  as 
the  result  of  reflex  irritation  such  as  gastrointestinal  troubles  (such 
as  worms,  overloading  the  stomach),  teething,  laryngitis,  scrofula, 
fright,  and  rickets.  It  occasionally  occurs  in  adults.  It  may  be 
hereditary.     Many  observers  believe  it  to  be  a  form  of  tetany. 

Pathology. — Death  rarely  occurs,  and  in  consequence  the  morbid 
anatomy  is  as  yet  undetermined.  The  mechanism  consists  in  an 
irritation  of  the  superior  laryngeal  nerve — the  afferent  nerve — whose 
function  is  to  supply  the  mucous  lining  of  the  larynx  with  sensibility, 
whence  is  reflected  through  the  inferior  laryngeal  nerve — the  efferent 
nerve — the  motor  influence  resulting  in  the  spasm  of  the  laryngeal 
muscles. 

Symptoms. — The  spasm  of  the  laryngeal  muscles  is  of  sudden 
onset,   and  usually  after  nightfall.     The  child  may  have  been  in 


LARYNGISMUS    STRIDULUS  48 1 

perfect  health,  to  all  appearances,  on  retiring,  or  it  may  have  shown 
symptoms  of  catarrh  of  the  upper  air  passages,  or  been  suffering 
from  aastrointestinal  or  dental  irritation.  The  child  awakens 
suddenly,  coughing  in  a  metallic,  resonant  tone — the  croupy  cough — 
and  with  great  dyspnea,  with  loud,  crowing,  stridulous  inspirations, 
the  result  of  narrowing  of  the  larynx  from  spasm,  and  with  wheezy, 
stridulous  expirations.  The  entrance  of  air  is  so  greatly  obstructed 
that  all  the  accessory  muscles  of  respiration  are  called  into  use; 
the  lips  and  finger  nails  become  blue,  the  surface  cold,  the  counte- 
nance anxious,  and  the  inferior  portion  of  the  chest  is  drawn  in, 
instead  of  being  expanded,  during  inspiration.  General  convulsions 
occur  at  times,  during  a  paroxysm,  also  strabismus,  and  involuntary 
discharges  of  the  feces  and  the  urine. 

The  paroxysm  continues  from  half  an  hour  to  an  hour  or  more, 
to  return  after  a  few  hours'  sleep  or  during  the  following  night;  the 
cough,  during  the  day,  having  the  croupy  character. 

Diagnosis. — The  non-febrile  and  distinctly  intermittent  character 
of  the  affection  with  its  peculiar  crowing  inspiration  differentiates 
it  from  other  laryngeal  conditions.  From  diphtheria  it  may  be 
recognized  by  the  history,  by  the  absence  of  membrane,  and  absence 
of  marked  local  inflammation. 

Prognosis. — Favorable.  Death  from  suffocation  during  the  parox- 
ysm may  occur  in  very  young  and  debilitated  children,  but  it  is  a 
very  rare  termination. 

Treatment. — The  inhalation  of  a  few  drops  of  chloroform  or 
amyl  nitrite  will  serve  to  relieve  the  paroxysm.  Nitroglycerin 
in  small  but  frequently  repeated  doses,  or  the  following  combination, 
is  a  valuable  antispasmodic: 

I^.     Potassii  bromid 5ij  8  gm. 

Chloral gr.  xxxij  2  gm. 

Syr.  aurantii  cort f 5j  30  c.c. 

Aquae  menth.  pip fSj  300.0. 

M.  S. — One  teaspoonful  every  half  hour. 

After  the  attacks  have  been  suspended,  the  tendency  to  recur- 
rence is  prevented  by  the  continued  use  of  potassium  bromide  in 
moderate  doses.  Cases  due  to  indigestion  are  greatly  relieved  during 
the  paroxysm  by  the  administration  of  an  emetic. 

Locally,  the  hot  pack,  alternating  with  the  cold  pack,  should  be 
31 


482  CHRONIC    LARYNGITIS 

applied  to  the  throat  continuously.     The  vapor  of  boiling  water 
should  be  inhaled  in  addition. 

After  the  attack  has  subsided  calomel  followed  by  magnesia  or 
castor  oil  should  be  given.  All  farinaceous  substances  should  be 
eliminated  from  the  diet,  and  tonics  should  be  administered.  The 
rachitic  factor  in  the  disease  should  also  receive  attention. 

CHRONIC  LARYNGITIS 

Causes. — Simple  chronic  catarrhal  inflammation  of  the  larynx 
may  be  due  to  repeated  acute  attacks,  or  may  follow  persistence  of 
the  same  causes  that  produce  the  acute  variety  such  as  overuse  of 
the  voice,  irritation  of  smoke,  vapors,  etc.,  and  excessive  use  of  alcohol 
and  tobacco. 

Pathological  Anatomy. — Redness  and  swelling  are  present  and 
there  is  more  or  less  thickening  of  the  parts  concerned  in  the  produc- 
tion of  the  voice.  Relaxation  of  one  or  both  vocal  cords  may  be 
observed.  Superficial  erosions,  distention  of  .the  follicles,  and 
villous  outgrowths  on  the  cords,  may  be  present. 

Symptoms. — Hoarseness  and  discomfort  in  the  use  of  the  voice 
are  the  most  prominent  symptoms.  Aphonia  may  occur.  There 
is  a  great  tendency  to  cough,  but  expectoration  is  scanty  and  mucoid 
in  character.  Inspection  reveals  swelling,  congestion,  and  a  granular 
appearance  of  the  larynx. 

Prognosis. — Owing  to  the  persistence  of  the  causes  and  the  in- 
ability of  the  patient  to  co-operate  in  the  treatment,  complete 
recovery  is  not  common.  Under  more  favorable  circumstances,  the 
prognosis  is  fairly  good. 

Treatment. — The  various  causes  should  be  ascertained  and 
promptly  removed.  Smoking,  and  drinking  of  alcoholic  beverages 
should  be  prohibited  and  the  patient  taught  to  properly  use  the 
voice.  Systematic  exercises,  fresh  air,  and  tonic  treatment  are 
indicated.  Associated  nasal  and  pharyngeal  affections  should  receive 
attention.  Astringent  sprays  such  as  alum  (3  per  cent.)  solution, 
tannin  solution  (i  to  2  per  cent.),  sulphate  of  zinc  (3  per  cent, 
solution),  etc.,  are  of  great  value  and  should  be  preceded  by  cleans- 
ing of  the  pharynx  and  larynx  with  Dobell's  solution  or  some 
similar  alkaline  mixture.  The  inhalation  of  steam  charged  with 
some  volatile  substance  such  as  benzoin,  benzoic  acid,  or  cubebs 
is  also  beneficial.     Troches  containing  benzoic  acid  (}i  gr.),  cubebs 


TUBERCULOUS    LARYNGITIS  483 

(i  to  2  gr.),  ammonium  chloride  (3  to  5  gr.),  potassium  chlorate  and 
borax  {2}^  gr.  of  each),  etc.,  are  productive  of  good  results.  In- 
sufflation of  dry  powders  such  as  starch  and  tannic  acid  (equal  parts) , 
alum  and  starch  (equal  parts),  iodoform,  and  similar  substances, 
into  the  larynx  often  affords  relief.  The  direct  application  of  silver 
nitrate  solution  (10  to  15  gr.  to  the  ounce),  or  a  solution  of  resorcin 
(10  pfer  cent.)  in  glycerin  to  the  diseased  areas  is  efficacious  in  many 
cases. 

SYPHILITIC  LARYNGITIS 

Syphilis  of  the  larynx  may  manifest  itself  as  a  diffuse  non-distinc- 
tive catarrhal  inflammation,  moist  papules  or  ''mucous  patches,"  or 
ulceration  (gumma).  The  mucous  patches  may  be  found  on  the 
epiglottis,  in  the  laryngeal  wall,  and  on  the  epiglottidean  folds,  but 
rarely  on  the  vocal  cords.  They  are  seldom  replaced  by  ulceration. 
Gumma  of  the  larynx  is  followed  by  circular,  deep,  and  sharply 
marginated  ulcers.  Perichondritis,  especially  of  the  cricoid  cartilage, 
is  present.  Rapid  necrosis  of  the  cartilages  is  common,  and  the 
resulting  cicatrix  may  give  rise  to  stenosis.  The  symptoms  are 
hoarseness,  cough,  more  or  less  loss  of  voice,  and  pain  on  deglutition. 

Diagnosis. — The  history,  the  rapidly  spreading  circumscribed 
ulcers,  and  the  results  of  specific  treatment  aid  greatly  in  distinguish- 
ing this  affection  from  tuberculous  laryngitis  in  which  there  are 
manifestations  of  tuberculosis  elsewhere  in  the  body. 

Prognosis. — Under  proper  treatment  the  ulcers  heal  rapidly,  but 
the  resulting  cicatrices  may  permanently  impair  the  voice. 

Treatment. — Mercury  and  the  iodides  should  be  administered  in 
full  doses  to  the  point  of  tolerance.  Locally,  astringent  and  alkaline 
sprays,  together  with  applications  of  silver  nitrate  (solid  stick  or  in 
solution)  or  chromic  acid  solution  (12.5  per  cent.)  to  the  ulcers,  are 
of  great  value.  Insufflation  of  iodoform  is  also  of  value.  The 
galvanocautery  directly  applied  to  the  ulcers  is  also  recommended. 
Zinc  chloride,  copper  sulphate,  and  similar  astringents  may  be  used 
with  benefit. 

TUBERCULOUS  LARYNGITIS 

Synonyms. — Laryngeal  phthisis;  throat  consumption. 

Definition. — A  tuberculous  inflammation  of  the  larynx,  char- 
acterized by  ulceration,  pain  on  deglutition,  cough,  weakness  of 
voice,  hectic  fever,  and  progressive  emaciation. 


484 


TUBERCULOUS    LARYNGITIS 


Cause. — The  affection  is  produced  by  the  tubercle  bacillus,  and 
may  be  primary,  but  is  generally  secondary  to  some  other  focus  of 
tuberculosis,  usually  in  the  lungs. 

Pathological  Anatomy. — All  laryngeal  affections  in  the  course  of 
phthisis  are  not  necessarily  tuberculous.  True  tuberculous  laryngi- 
tis begins  with  redness  of  the  mucous  membrane,  showing  scattered 
tubercles.  The  tubercles  show  a  strong  tendency  to  cluster,  then 
soften,  leaving  shallow,  irregular  ulcers.  The  parts  chiefly  affected 
are  the  posterior  portion  of  the  vocal  cords,  and  the  epiglottis.  The 
ulcers  are  covered  with  a  grayish  exudate.  The  mucous  tissue  round 
about  the  ulcers  is  thickened.  The  ulcers  may,  and  generally  do, 
erode  the  true  vocal  cords,  often  entirely  destroying  them.  The 
ulcers  slowly  extend  in  all  directions,  destroying  the  tissues  attacked. 
The  epiglottis  may  be  entirely  destroyed. 

Laryngeal  tuberculosis  and  syphilis  may  be  differentiated  as 
follows : 


Tuberculosis 


Syphilis 


Pain  severe  on  deglutition . 

Ulcerates  slowly 

Usually  first  appears  as  small  spots  or 
nodules  which,  are  rapidly  followed  by 
great  edema. 

Ulcers  extend  laterally  but  not  deeply 


Mucous  membrane  usually  pale 

Health  impaired  previous  to  laryngeal  in- 
volvement. 

Previous  or  coincident  pulmonary  trouble 
common. 

Iodides  have  no  influence 


Pain  usually  slight. 

Ulcerates  rapidly. 

Is  rarely  seen  in  stage  of  induration,  the 

first    evidence    being    a    clear-cut,    deep 

ulcer. 
Ulcers     extend     deeply,     often     involving 

cartilage. 

Mucous     membrane   hyperemic,    injected. 
General  health  unimpaired. 

Frequently  evidence  of  syphilitic  disease 

in  other  tissues. 
Readily  improves  under  iodides. 


{From  Gibb's  table,  as  modified  by  Coakley.) 

Symptoms. — The  first  symptom  is  a  change  in  the  voice — huski- 
ness;  this,  associated  with  symptoms  of  ill-health,  is  always  a  warning 
to  the  physician.  The  husky  voice  may  proceed  until  it  is  but  a 
painful  whisper.  Cough  of  an  irritating,  painful  character  is  present, 
associated  with  slight  expectoration.  Painful  and  difficult  degluti- 
tion (dysphagia)  is  a  very  constant  and  distressing  symptom.  There 
is  the  remitting  fever  so  characteristic  of  tuberculosis,  with  night- 
sweats,  loss  of  appetite,  loss  of  flesh,  and  insomnia. 

Laryngoscopic  examination  reveals  the  characteristic  broad, 
shallow,  irregular,  grayish  ulcers,  with  the  thickened  surrounding 
mucous  membrane.  The  vocal  cords  show  infiltration  and  thicken- 
ing or  ulceration. 


ACUTE   BRONCHITIS  485 

Diagnosis. — While  the  broad,  shallow,  irregular  ulcers  are  fairly 
characteristic  of  this  disease,  no  positive  diagnosis  can  be  made 
until  the  sputum  is  examined  and  tubercle  bacilli  found  therein. 

Prognosis. — Unfavorable . 

Treatment. — The  general  treatment  is  that  of  tuberculosis  else- 
where in  the  body.  The  diet  should  be  liquid  and  concentrated, 
on  account  of  the  distress  and  difficulty  in  swallowing.  Much  can 
be  done  by  local  treatment  to  render  the  patient  comfortable.  The 
application  of  lactic  acid  (20,  40,  or  60  per  cent,  solution)  to  the 
larynx  is  very  beneficial.  Cocaine  similarly  employed  is  also  of 
value  in  relieving  the  pain  and  dysphagia.  Hydrogen  peroxide, 
silver  nitrate,  and  menthol  may  be  used  with  good  results.  Curet- 
ting of  the  ulcers  and  applying  iodoform  in  emulsion  or  with  morphine 
sulphate  has  been  practised  with  benefit.  Alkaline  washes  and 
sedative  inhalations  are  also  recommended. 

DISEASES  OF  THE  BRONCHIAL  TUBES 

ACUTE  BRONCHITIS 

Synonyms. — Bronchial  catarrh;  acute  bronchial  catarrh;  "cold 
on  the  chest." 

Definition. — An  acute  catarrhal  inflammation  of  the  bronchial 
mucous  membrane,  characterized  by  fever,  substernal  pain,  a  feeling 
of  thoracic  constriction,  oppression  in  breathing,  and  at  first  scanty, 
followed  by  more  or  less  profuse,  expectoration. 

Causes. — It  is  most  frequent  in  childhood,  especially  during  the 
period  of  dentition,  when  there  exists  a  strong  tendency  to  catarrh 
of  the  mucous  membranes  in  general  and  of  the  bronchi  in  particular. 
In  old  age  the  predisposition  again  returns.  Inhalation  of  irritants 
such  as  dust,  smoke,  and  air  too  hot  or  too  cold,  is  also  a  common 
cause.  The  affection  is  more  common  in  climates  characterized  by 
considerable  moisture  of  the  atmosphere,  combined  with  a  low  tem- 
perature, and  especially  where  there  are  sudden  and  marked  varia- 
tions. Chronic  heart  disease,  uric  acid  diathesis,  and  exposure  to 
cold  and  wet  are  potent  etiological  factors.  It  accompanies  the 
infectious  fevers  such  as  typhoid  fever,  influenza,  whooping  cough, 
and  measles.  The  exciting  cause  is  a  microorganism;  staphylococci, 
streptococci,  or  pneumococci  may  be  found  in  the  sputum. 

Pathological  Anatomy. — The  mucous  membrane  of  the  bronchial 


486  ACUTE   BRONCHITIS 

tubes  is  at  first  i;ongested,  swollen,  and  edematous.  Secretion  is 
diminished.  Later,  there  are  increased  secretion  and  overgrowth 
and  desquamation  of  the  epithelium  together  with  proliferation  of 
young  cells  and  leukocytic  infiltration.  The  expectoration  is  then 
of  a  yellowish  color  (muco-purulent) .  In  the  early  stage  the  scant 
expectoration  may  be  streaked  with  blood  due  to  rupture  of  the 
distended  capillaries. 

In  cases  of  bronchitis  following  the  exanthemata,  or  in  scrofulous 
patients,  the  bronchial  glands  participate  in  the  inflammation,  becom- 
ing hyperemic,  swollen,  and  filled  with  a  secretion,  and  not  infre- 
quently the  glandular  elements  undergo  a  hyperplasia,  and  finally 
"cheesy"  degeneration. 

Symptoms. — The  invasion  may  be  attended  by  nasal  or  laryngeal 
catarrh,  or  both.  Usually  the  onset  begins  with  chilliness,  followed 
by  flushes  of  heat,  aching  pain  of  a  contused  character  in  the  limbs, 
joints,  and  trunk,  with  a  sense  of  fatigue  and  loss  of  energy,  furred 
tongue,  anorexia,  and  constipation.  In  nervous,  irritable  individuals 
and  in  children,  there  may  be  slight  delirium,  and  in  very  young 
children  during  the  period  of  dentition,  convulsions  may  often  usher 
in  an  attack. 

After  a  day  or  two  of  these  initial  symptoms,  those  characteristic 
of  bronchial  catarrh  develop. 

Pain  is  experienced  beneath  the  sternum,  especially  toward  its 
upper  part,  of  a  raw,  '  uming,  or  tearing  character,  aggravated  by  a 
deep  inspiration  or  by  coughing;  the  pain  also  radiates  toward  the 
sides,  following  the  course  of  the  primary  bronchial  tubes.  Tender- 
ness over  the  sternum  is  often  experienced.  Muscular  pain  and 
tenderness  of  rheumatic  character  are  often  associated  with  attacks 
of  bronchitis.  Cough  is  present  from  the  onset,  at  first  in  paroxysms 
of  a  hard,  dry  character,  changing  as  the  disease  progresses,  and 
becoming  looser,  followed  by  free  expectoration.  The  expectoration, 
at  first,  is  small  in  quantity,  almost  transparent,  frothy,  often 
streaked  with  blood,  and  having  a  salty  taste.  As  the  disease  pro- 
gresses it  becomes  more  abundant,  of  a  yellowish  or  a  greenish- 
yellow  color,  and  of  a  tenacious  consistency.  There  are  present 
slight  fever,  hot,  dry  skin,  frequent  pulse,  loss  of  appetite,  moderate 
thirst,  and  constipation.  A  feeling  of  languor  and  weariness,  and 
often  considerable  depression,  quite  out  of  proportion  to  the  febrile 
state,  are  not  infrequent. 

Physical  Examination. — On  inspection,  palpation,  and  percussion 


ACUTE   BRONCHITIS 


487 


there  are  no  evidences  of  any  abnormal  condition.  Auscultation, 
however,  reveals,  in  the  early  stage,  the  presence  of  dry  rMes,  sonor- 
ous and  sibilant,  on  both  sides  of  the  chest,  and  harsh  breath  sounds; 
in  the  later  stage  when  expectoration  is  profuse,  moist  bubbling 
rMes  are  heard. 

Diagnosis. — The  points  of  resemblance  and  difference  between 
acute  bronchitis  and  other  diseases  of  the  chest  will  be  pointed  out 
when  those  affections  are  described.  The  most  likely  conditions 
to  be  confused  with  acute  bronchitis  are  bronchopneumonia  and 
influenza;  the  chief  points  of  difference  are  shown  in  the  following 
table  from  Gould  and  Pyle's  Cyclopedia  of  Medicine  and  Surgery: 


Acute  bronchitis 


Influenza 


Bronchopneumonia 


Subjective  symptoms. 

1.  May  occur  at  any  age. . 

2.  Pain  in  region  of  ster- 
num. 

Objective  symptoms. 
I.  Respirations  normal  or 
only  slightly  increased. 


2.  Fever  slight  or  entirely    2. 
absent;    pulse    in    pro- 
portion. 

3.  In  early  stages  sonorous 
and  sibilant  rSles;  later, 
mucous  rS.les  are  heard. 


Subjective  symptoms. 
May  occur  at  any  age. . .  . 

Pain  in  forehead  or  back 
of  neck;  general  bodyache. 
Objective  symptoms. 
Respirations    slightly    in- 
creased. 

Pulse  small,  rapid,  irreg- 
ular, moderate  and  often 
high  fever   (103°  to    104° 

Same  as  acute  bronchitis. 


Subjective  symptoms. 
Most   frequent    in   young 
or  very  old. 
Pain  in  region  of  chest. 

Objective  symptoms. 
Respirations  exaggerated; 
dyspnea  may  he  present; 
livid  color  of  lips. 
High    fever;    pulse  rapid 
and  feeble. 


Subcrepitant     r^les     over 
base  of  lungs  posteriorly. 


The  association  of  bronchitis  with  other  diseases  must  not  be  for- 
gotten. 

Prognosis. — Acute  bronchitis  of  the  larger  tubes  usually  terminates 
in  complete  resolution  within  two  weeks.  In  children  and  in  the 
aged,  the  course  is  more  protracted,  and  the  symptoms  more  severe, 
but  recovery  is  the  rule.  Very  aged  and  feeble  persons  may  rarely 
succumb. 

Treatment. — The  patient  should  be  confined  to  a  warm  but  well- 
ventilated  room,  and  if  aged  or  extremely  young  and  feeble,  placed 
in  bed.  Soft  diet  should  be  prescribed.  A  free  movement  of  the 
bowels  should  be  obtained  by  the  administration  of  fractional  doses 
of  calomel  followed  by  magnesia  or  some  other  saline.  The  action 
of  the  skin  should  be  rendered  free  by  the  employment  of  the  hot 
foot-bath,  hot  drinks,  and  Dover's  powder.  During  the  stage  of 
invasion,  quinine  sulphate,  gr.  x  (0.6  gm.),  combined  with  morphine 


488  ACUTE  BRONCHITIS 

sulphate,  gr.  J^  (o.ii  gm.),  will  usually  prevent  or  abort  an  attack. 
^  In  the  first  stage,  in  adults  when  the  mucous  membrane  is  swollen  and 
dry,  the  sedative  expectorants  or  either  of  the  following  prescriptions 
will  give  prompt  relief: 

I^.     Antimonii  et  potassii  tart .  .    gr.  ij  0.13  gm. 

Liquor,  ammonii  acetatis.  .    5iv  120.0  c.c. 

Spt.  astheris  nitrosi 5j  30.0  c.c. 

(Tinct.  aconiti,  if  indicated)    5iij  12.0  c.c. 

Syr.  simplicis ad   §vj  ad        180.0  c.c' 

M.  S. — Two  teaspoonfuls  every  two  or  three  hours. 
Or— 

I^.     Vini  ipecacuanhse f  5j  4  c.c. 

Liq.  potassii  citrat f  5iij  90  c.c, 

Liq.  ammonii  acetat f  Biij  90  c.c. 

M.  S. — Tablespoonful  every  two  or  three  hours. 

If  the  cough  of  the  dry  stage  is  severe  or  if  diarrhea  follow  the  use 
of  either  of  the  above  combinations,  camphorated  tincture  of  opium 
(paregoric)  or  codeine  or  heroine,  may  be  added  with  advantage,  but 
caution  should  always  be  exercised  in  the  use  of  opium  in  the  dry 
stage.  Tincture  of  hyoscyamus,  TTlx  to  xv  (0.3  to  i  c.c),  may  be 
employed  instead. 

For  young  children,  the  above  combinations  in  proportionately 
reduced  doses  or  the  following  may  be  used  with  benefit: 

I^.     Pulv.  ipecac,  et  opii gr.  V  0.3    gm. 

Pulv.  scillae gr.  x  0.6    gm. 

Hydrargyri  chlor.  mitis. . . .  gr,  ij  .            o.  13  gm. 

Sacch.  lact .  .  .  gr.  x  0.6    gm. 

M.     Ft.  chart.  No.  x. 
S. — One  every  two  hours. 

The  following  is  an  excellent  mixture  for  children: 

I^.      Potassii  citrat 5ij  8  gm. 

Syr.   ipecac f  5ij  8  c.c. 

Syr.  scillse f  5  j  4  c.c. 

Syr.  limonis f  5ij  8  c.c. 

Tinct.  opii  camphorat f  5ij  8  c.c. 

Elix.  simplicis q.  s.  ad  f§iij  q.  s.  ad     90  c.c. 

M,  S. — Teaspoonful  every  two  hours. 


CHRONIC   BRONCHITIS  489 

Locally,  in  this  stage,  counterirritation  is  often  of  great  value. 
Mustard  plasters,  or  turpentine  stupes,  or  even  a  few  dry  or  wet 
cups  over  the  sternum  will  in  many  cases  serve  to  relieve  the  sub- 
sternal pain  and  bronchial  congestion. 

Second  Stage. — The  secretion  of  the  bronchial  mucous  membrane 
being  copious,  stimulating  expectorants  are  indicated,  such  as  ammo- 
nium chloride,  ammonium  carbonate,  squill,  potassium  carbonate, 
etc.     A  reliable  combination  is: 

I^.      Ammonii  chloridi 5ij  8  gm. 

Aceti  scillse f  3iij  12  c.c. 

Syr.  ipecac f  5ij  8  c.c. 

Mist,  glycyrrhizae  comp. 

q.  s.  ad  f  Biij      q.  s.  ad  90  c.c. 
M.  S. — Dessertspoonful  every  three  hours. 

Attacks  showing  a  tendency  to  linger  are  greatly  benefited  by  the 
following : 

I^.     Terebeni f5ij  8.0  c.c. 

Creosoti lUxxiv  i .  5  c.c. 

Mucil.  acacias q.  s.  q.  s. 

Aquae  chlorof ormi .  .  .  .q.  s.    f  Siij    q.  s.  ad     90.0  c.c. 
M.  S. — One  teaspoonful  every  four  hours,  diluted. 

In  debilitated  individuals,  alcohol  and  strychnine  are  necessary 
to  overcome  the  depression.  During  convalescence  these  and  other 
tonics  such  as  iron,  quinine,  and  cod-liver  oil  are  indicated.  A  change 
of  climate  is  beneficial. 

CHRONIC  BRONCHITIS 

Synonyms. — Chronic  bronchial  catarrh;  winter  cough;  secondary 
bronchitis. 

Definition. — A  chronic  inflammation  of  the  mucous  membrane 
of  the  larger  and  middle-sized  bronchial  tubes;  characterized  by 
cough  and  more  or  less  profuse  expectoration,  plus,  in  many  cases, 
the  symptoms  of  emphysema  of  the  lungs.  Chronic  bronchitis 
may  be  either  primary  or  secondary. 

Causes. — It  may  follow  a  succession  of  acute  attacks,  or  it  may 
be  due  to  exposure  to  cold  and  wet  or  the  repeated  inhalation  of 
dust,  vapors,  or  other  irritants.  It  is  common  in  the  aged.  The 
affection  may  accompany  the  infectious  fevers,  as  typhoid  fever, 


490  CHRONIC  BRONCHITIS 

influenza,  measles,  etc.,  and  pulmonary,  cardiac,  or  renal  disease, 
or  it  may  arise  indirectly  from  gout,  rheumatism,  syphilis,  and 
alcoholism. 

Varieties. — I.  Mucous  catarrh,  associated  with  moderate  expectora- 
tion. II.  Bronchorrhea,  profuse  expectoration.  III.  Dry  catarrh, 
scanty  expectoration.  IV.  Fetid  bronchitis.  V.  Bronchiectasis, 
or  dilatation  of  the  bronchi.  « 

Pathological  Anatomy. — The  mucous  membrane  of  the  bronchial 
tube  is  discolored,  being  of  a  more  or  less  dull  red,  often  of  a  deeply 
venous  blue,  mingled  with  a  grayish  or  brownish  color.  These 
changes  may  be  either  in  patches  or  extensively  diffused.  The 
vessels  of  the  mucous  membrane  are  dilated.  The  mucous  membrane 
is  thickened,  resulting  in  reduction  in  the  caliber  of  the  tube  and  a 
roughening  of  its  internal  surface.  Later,  the  mucous  membrane 
may  become  atrophied,  and  minute  ulcers  may  appear.  The  sub- 
mucous tissue  becomes  infiltrated,  contracted,  and  indurated.  The 
elastic  and  muscular  coats  of  the  tubes  become  hypertrophied,  lose 
their  elasticity,  and  the  cartilages  become  the  seat  of  calcareous 
deposits. 

As  the  result  of  the  loss  of  elasticity  and  muscular  tone  of  the 
tubes  they  become  irregularly  dilated — '' bronchial  dilatation. '' 
The  dilatations  may  be  uniform  in  character,  resembling  somewhat 
the  fingers  of  a  glove,  or  they  may  be  sacculated  or  globular,  forming 
actual  cavities  in  the  bronchial  structure. 

In  the  mucous  variety  the  secretion  consists  of  young  cells  and 
mucous  corpuscles,  having  a  yellowish  color;  in  the  dry  variety, 
the  "catarrhe  sec"  of  Laennec,  or  "dry  bronchial  irritation,"  the 
secretion  is  scanty,  tough,  semi-transparent,  and  occurs  in  globular 
masses;  in  bronchorrhea,  which  is  usually  associated  with  bronchial 
dilatation,  the  secretion  is  abundant,  greenish  yellow  in  color,  and 
frequently  fetid. 

The  majority  of  cases  of  chronic  bronchitis  are  associated  with 
chronic  gastric  catarrh. 

Symptoms. — The  most  characteristic  symptoms  of  chronic  bron- 
chitis are  the  cough  and  expectoration.  The  cough  may  occur  at 
all  hours,  but  is  more  severe  at  night  and  early  in  the  morning.  The 
cough  is  not  always  present;  it  disappears  almost  altogether  for  a 
time,  and  then  reappears,  continuing  thus  for  years.  Coated  tongue, 
disagreeable  taste,  loss  of  appetite,  impaired  digestion,  with  eructa- 
tions of  gases,  are  present  in  many  cases,  due  to  the  chronic  gastric 


CHRONIC   BRONCHITIS  49 1 

catarrh.  Unless  associated  with  other  diseases,  1:he  general  health 
suffers  but  little,  if  at  all;  constitutional  symptoms  being  present 
only  during  acute  exacerbations. 

Mucous  catarrh,  or,  from  its  occurring  most  commonly  during  the 
winter  months,  "winter  cough,"  is  characterized  by  paroxysms  of 
cough,  more  or  less  violent,  followed  by  the  expectoration  of  a 
yellowish  mucus. 

Dry  catarrh  is  characterized  by  a  harsh  cough,  a  feeling  of  sore- 
ness or  rawness  under  the  sternum,  and  the  expectoration  of  small 
globular  masses;  this  variety  occurs  with  emphysema,  gout,  rheu- 
matism, and  asthma. 

Bronchorrhea,  which  is  associated  with  bronchial  dilatation, 
and  most  common  in  the  elderly,  is  characterized  by  paroxysms  of 
severe  coughing,  followed  by  the  copious  expectoration  of  greenish 
yellow,  often  fetid,  mucus;  the  quantity  expectorated  often  amounts 
to  four  or  five  pints  in  the  twenty-four  hours. 

Fetid  bronchitis,  often  associated  with  bronchial  dilatation,  has 
an  excessively  fetid  odor  of  the  breath  and  expectoration.  The 
decomposition  of  the  secretion  may  cause  gangrene  of  the  bronchial 
mucous  membrane,  and  even  of  the  lung-structure. 

Physical  Signs. — Percussion  yields  a  normal  note  in  simple,  un- 
complicated cases.  In  the  presence  of  bronchial  dilatation  there 
are  diffused  spots  of  the  tympanitic  or  amphoric  percussion-sound, 
the  physical  condition  being  a  circumscribed  cavity  containing 
air  and  communicating  with  a  bronchial  tube. 

Auscultation  reveals  the  presence  of  harsh  or  vesiculo-bronchial 
respiration  associated  with  more  or  less  profuse,  sonorous,  sibilant, 
and  large  and  small  bubbling  rales;  in  bronchial  dilatation,  in  addi- 
tion to  the  harsh  respiration,  is  found  broncho-cavernous  breathing, 
with  large  and  small  gurgling  rales.  Should  emphysema  complicate 
chronic  bronchitis,  the  physical  signs  are  somewhat  modified,  and 
will  be  pointed  out  when  discussing  that  affection. 

Diagnosis. — Always  examine  the  urine  in  case  of  cough,  and 
particularly  in  chronic  bronchitis,  as  this  condition  is  one  of  the 
most  frequent  complications  of  B right's  disease. 

Incipient  phthisis  is  often  confounded  with  chronic  bronchitis. 
The  diagnosis  is  not  always  easy.  The  physical  signs  of  chronic 
bronchitis  are  more  or  less  diffused  through  both  lungs,  and  not, 
as  a  rule,  associated  with  failure  of  the  general  health;  while  in  phthi- 
sis, from  the  onset,  there  is  failing  health,  with  a  concentration  of 


492  CHRONIC   BRONCHITIS 

the  physical  signs  to  the  apices.  The  discovery  of  the  tubercle  bacil- 
lus determines  the  diagnosis. 

Bronchiectasis  may  be  distinguished  from  chronic  bronchitis  by 
the  paroxysmal  coughing,  copious  expectoration,  and  physical  signs 
indicating  one  or  more  cavities  near  the  base  of  the  lung. 

Emphysema  is  characterized  by  uniform  distention  of  the  chest, 
dyspnea,  hyper-resonance,  and  feeble  expiration. 

Asthma  is  attended  by  marked  dyspnea,  hyper-resonance  on  per- 
cussion, dry  and  moist  rales  on  auscultation,  and  expectoration  of 
Curschmann's  spirals  and  Charcot-Leyden  crystals. 

Prognosis. — If  unassociated  with  disease  of  the  lungs,  heart, 
or  kidneys,  chronic  bronchitis  is  never  dangerous  to  life,  although 
the  symptoms  are  present,  more  or  less,  continually,  and  aggravated 
upon  the  least  exposure.     Rarely  is  a  complete  cure  recorded. 

If  associated  with  phthisis,  emphysema,  diseases  of  the  heart  or  of 
the  kidneys,  the  prognosis  is  governed  by  these  affections.  In  turn, 
it  is  to  be  remembered  that  chronic  bronchial  catarrh  may  lead  to  em- 
physema of  the  lungs,  bronchiectasis,  asthma,  or  to  cardiac  dilatation. 

Treatment. — In  all  cases,  a  careful  examination  should  be  made  of 
all  the  organs  to  determine  whether  the  affection  is  primary  or  secon- 
dary. When  dependent  upon  some  other  disease  the  greater  portion 
of  the  treatment  should  be  directed  toward  the  underlying  condition. 
Warmth  is  beneficial  in  all  cases.  The  patient  should  be  protected 
from  cold  by  wearing  woolen  or  silk  underclothing  the  year  round, 
being  careful,  however,  not  to  clothe  to  excess.  Draughts,  wet  feet, 
etc.,  should  be  guarded  against.  A  warm  atmosphere  is  especially 
beneficial,  and  when  possible  the  patient  should  be  removed  to  a 
warm  climate.  If  the  expectoration  is  profuse,  a  warm  dry  climate 
is  indicated,  but  if  the  expectoration  is  very  scant,  the  opposite,  a 
moist,  warm  climate  is  recommended. 

The  medicinal  treatment  has  for  its  object  the  restoration  of  the 
normal  tone  of  the  body  and  the  lessening  of  the  local  inflammation. 
The  first  indication  is  met  with  by  the  administration  of  iron,  quinine, 
strychnine,  arsenic,  cod-liver  oil,  etc.  In  the  presence  of  organic 
disease  special  medicinal  treatment  is  required  in  addition.  In  cases 
dependent  upon  the  uric  acid  diathesis  the  iodides  and  alkalies  should 
be  administered  over  an  extended  period,  and  the  patient  should  be 
advised  to  seek  a  residence  at  one  of  the  alkaline  springs.  When  the 
condition  is  associated  with  alcoholism  or  chronic  gastric  catarrh, 
the  following  combination  is  of  value: 


CHRONIC   BRONCHITIS  493 

I^.     Ammonii  chloridi 3iij  12  gm. 

Tinct.  nucis  vomicae f  5ij  8  c.c. 

Infus.  gentianae  comp., 

q.  s.  ad  f  Biv  q.  s.  ad       120  c.c. 

M.  S. — Dessertspoonful  in  water  before  meals. 

The  bronchial  inflammation  itself  calls  for  the  use  of  stimulating 
expectorants,  prominent  among  which  may  be  mentioned  ammonium 
chloride,  ammonium  carbonate,  benzoic  acid,  balsams  of  Peru  and 
Tolu,  tar,  squill,  turpentine,  oil  of  eucalyptus,  terebene,  sandal  wood 
oil,  cubebs,  copaiba,  creosote,  and  terpene  hydrate. 

For  mucous  catarrh  with  acute  exacerbations: 

I^.     Ammonii  chloridi 5ij  8.0      gm. 

Glycerini fSjss  45 -O      c.c. 

Codeinae  sulph gr.  j  o .  065  gm. 

Vini  picis  liq f  Siij  90.0      c.c. 

Syr.  prun.  virg f  B  jss  45-0      c.c. 

M.  S. — Tablespoonful  every  three  or  four  hours. 

Dry  catarrh  is  greatly  benefited  by : 

I^.     Potassii  iodidi gr.  v  to  x    o .  3  to  o .  6  gm. 

Elix.  cinchonae TTlxx  i .  3  c.c. 

Vini  picis  liq ad  f  5  ss  ad     15.0  c.c. 

M.  S. — Three  times  a  day. 

For  an  acute  exacerbation  of  dry  or  tenacious  chronic  bronchitis: 

I^.     Ammonii  chloridi 5iv"  15  gm. 

Tinct.  hyoscyam f  3iv  15  c.c. 

Syr.  scillae  comp f  5iv  15  c.c. 

Aq.  chloroform! f  gij  60  c.c. 

M.  S. — One  teaspoonful  every  three  hours,  diluted. 

An  excellent  expectorant  combination  in  all  forms  and  at  any  stage 
of  bronchial  catarrh  is: 

I^.     Ammonii  carbonat gr.  xvj  i  gm. 

Fluidextracti  scillae f  3ss  2  c.c. 

Fluidextracti  senegse f  5ss  2  c.c. 

Tinct.  opii  camphorat f  5iij  12  c.c. 

Syr.  Tolu f  5  jss  45  c.c. 

M.  S. — Teaspoonful  every  few  hours,  diluted. 
Or— 


494  CHRONIC  BRONCHITIS 

I^.     Fluidextracti  eucalypti.  ..  .     Bj  30  gm. 

Ammonii  chlorid 5j  4  gm. 

Ext.  glycyrrhizae 5ij  ,  8  gm. 

Syrup.  Tolutani f  5iij  90  c.c. 

M.  S. — One  teaspoonful  every  three  hours.     {Potter.) 
Or— 

'^,.     Ammonii  chlorid gr.  xxx  2  gm. 

Tr.  opii  camph. 

Syr.  ipecac ad  f  5iij  ad       11  c.c. 

Syr.  pruni  Virg f  §j  30  c.c. 

Syr.  Tolutani q.  s.  ad  f  §iv  q.  s.  ad  120  c.c. 

M.  S. — Teaspoonful  every  three  hours. 
Or— 

I^.     Acid  hydrocyanici  dil ITtxx  1.23  c.c. 

Ammonii  carb gr.  xl  2.6    gm. 

Syr.  Tolutani fSiv  120.0    c.c. 

Aquae q.  s.  ad  f §viij  q.s.ad  240.0    c.c. 

M.  S. — Four  teaspoonfuls  every  three  hours. 
Or— 

I^.     Syr.  scillae fBss  15  c.c. 

Tr.  opii  camph f  5ij  8  c.c. 

Ammoniac 5ss  2  gm. 

Syrup  Tolutani f  3x  38  gm. 

M.  S. — Teaspoonful  as  the  occasion  requires.       (Potter.) 

In  the  bronchorrheal  type  of  the  disease,  copaiba,  TTtv  to  x  (0.3  c.c. 
to  0.6  c.c),  every  three  hours,  spirit  of  turpentine,  TTtv  (0.3  c.c),  every 
four  hours,  carbolic  acid,  gr.  ss  (0.032  gm.),  four  times  daily,  or  the 
following  combination  should  be  administered. 

I^.     Terebeni f  3ij  8  c.c. 

Creosoti TTlxxx  2  c.c. 

Acaciae q.  s.  q.  s. 

Aq.  chloroform! fBj  30  c.c. 

Syr.  prun.  virg. . .  .q.  s.  ad  f  Biij      q.  s.  ad        90  c.c. 
M.  S. — Teaspoonful  every  three  or  four  hours,  diluted. 
Or— 

I^.     Copaibae, 

Syr.  Tolutani aa     5iv  15  c.c. 

Spt.  etheris  nitrosi f  §j  30  c.c. 

Aquae  menth.  pip f  §ij  60  c.c. 

M.  S. — Teaspoonful  every  four  hours.     (Potter). 


FIBRINOUS   BRONCHITIS  495 

In  fetid  bronchitis,  DaCosta  recommends  the  internal  adminis- 
tration of  carbolic  acid,Tlflj  (0.06  c.c),  every  third  hour  with  inhala- 
tions of  the  vapor  of  water  containing  carbolic  acid,  gr.  v  (0.32  gm.), 
to  the  fluidounce  (30  c.c),  two  or  three  times  daily.  The  following 
inhalation  may  also  be  used: 

I^.     Creosote  (beechwood) f  5j  4  c.c. 

Eucalyptol f  5j  4  c.c. 

Tr.  benzoin  comp. . ; f  gij  60  c.c. 

M.  S. — Add  one  teaspoonful  to  a  pint  of  boiling  water  and  use 
as  an  inhalation  twice  daily. 

Locally,  counterirritation  in  the  form  of  flying  blisters,  or  tincture 
of  iodine  repeated  once  or  twice  a  week  is  of  advantage. 

FIBRINOUS  BRONCHITIS 

Sjoionyms. — Plastic  bronchitis;  membranous  bronchitis. 

Definition. — An  acute  inflammation  of  the  mucous  membrane 
of  the  larger  and  middle-sized  bronchial  tubes,  attended  with  an 
exudation,  forming  a  membranous  layer,  which  is  closely  adherent 
to  the  mucous  surface;  characterized  by  febrile  reaction,  cough,  difii- 
cult  breathing,  and  scanty  expectoration,  followed  by  the  expulsion 
of  the  false  membrane  in  the  form  of  patches  or  casts. 

Causes. — The  direct  cause  is  unknown.  The  affection  is  frequently 
associated  with  tuberculosis;  less  often  with  other  conditions,  such 
as  membranous  laryngitis,  asthma,  emphysema,  typhoid  fever, 
pneumonia,  certain  skin  diseases,  or  disturbances  of  menstruation. 
It  may  occur  in  those  of  feeble  health,  or  in  tuberculous  constitutions, 
so-called,  or  it  may  result  from  exposure  to  cold  and  damp.  Spring 
season,  adult  life,  and  male  sex  are  predisposing  factors. 

Pathological  Anatomy. — The  affection  begins  with  hyperemia 
of  the  mucous  membrane  of  the  bronchial  tubes,  associated  with 
swelling  and  edema.  Later  the  surface  is  covered  with  a  whitish  or 
grayish-white,  firmly  adherent,  membranous  deposit,  cemented 
together  by  a  coagulable  exudation  and  prolonged  from  its  under 
surface  into  the  bronchial  follicles.  Sooner  or  later  it  is  loosened 
and  detached  by  a  suppurative  process  and  is  expectorated  after  a 
violent  paroxysm  of  coughing  or  vomiting.  When  expectorated, 
the^  false  membrane,  as  it  has  been  termed,  has  either  the  form  of 
patches,  or  is  thrown  off  entire  from  the  bronchial  tube,  and  may  be 


496  FIBRINOUS   BRONCHITIS 

found  to  consist  of  casts  representing  more  or  less  of  the  bronchial  sub- 
divisions, and  presenting  an  appearance  not  unlike  ''boiled  macaroni." 

On  microscopic  examination,  the  detached  membrane  presents  fibrillae 
which  characterize  fibrin  or  lymph  in  other  situations;  and  if  placed 
in  a  solution  of  acetic  acid,  it  becomes  greatly  swollen,  while  ordinary 
mucus  contracts  and  becomes  more  dense  if  added  to  the  same  solu- 
tion. Charcot-Leyden  crystals,  Curschmann's  spirals,  leukocytes, 
fat-droplets,  and  epithelium  may  be  found  in  the  casts. 

Symptoms. — There  are  no  symptoms  or  signs  by  means  of  which 
this  variety  of  bronchitis  can  be  distinguished  from  ordinary  catarrhal 
bronchitis,  prior  to  the  expectoration  of  the  false  membrane. 

Expectoration  is  preceded  and  accompanied  by  violent  paroxysms 
of  coughing,  and  after  more  or  less  of  the  membrane  has  been  raised, 
a  muco-purulent  expectoration,  streaked  with  blood,  may  be  present 
for  several  days. 

Duration. — The  inflammation  may  be  either  acute,  subacute,  or 
chronic,  expectoration  of  patches  or  strips  of  the  membrane  being 
repeated  at  intervals  of  days,  weeks,  months,  or  even  years. 

Prognosis. — In  adults,  the  outlook  is  favorable,  if  not  associated 
with  other  grave  affections,  such  as  phthisis,  pneumonia,  emphysema. 
In  young  children  it  may  cause  obstruction  to  the  respiration,  and 
not  infrequently  proves  fatal.     The  acute  form  is  most  serious. 

Treatment. — As  the  character  of  the  inflammation  can  seldom 
be  determined  until  the  membrane  or  portions  of  it  have  been  ex- 
pectorated, the  treatment  is  at  first  the  same  as  in  attacks  of  ordi- 
nary acute  bronchitis. 

As  soon,  however,  as  the  character  of  the  inflammation  can  be 
determined,  active  emesis  is  the  most  effective  means  of  removing 
the  obstruction  caused  by  the  false  membrane,  the  best  agents  of 
this  class  being  yellow  mercuric  subsulphate  (turpeth  mineral),  apo- 
morphine,  ipecac,  and  zinc  sulphate.  Inhalations  of  the  vapor  of 
alkaline  solutions  such  as  lime-water  and  solution  of  sodium  bicar- 
bonate, gr.  XXX  to  the  fluidounce  (2  gm.  to  30  c.c),  ammonium 
chloride,  tar  (pix  liquida),  and  eucalyptol  may  also  be  employed 
in  inhalations.  To  prevent  the  formation  of  the  membrane,  Bartho- 
low  urges  the  use  of  ammonium  iodide  and  ammonium  carbonate 
combined,  in  small  doses  every  two  hours.  Potassium  iodide  is  also 
of  value.  Counterirritation  to  the  chest  is  of  benefit  in  cases  which 
tend  to  become  chronic.  Arsenic  and  pix  liquida  should  also  be  given 
in  these  cases. 


HAY  FEVER  497 

HAY  FEVER 

Synonyms.— Hay  asthma;  autumnal  catarrh;  rose  cold. 

Definition. — An  acute,  catarrhal  inflammation  of  the  upper  air- 
passages,  extending  to  the  bronchial  tubes,  associated  with  spasmodic 
contraction  of  their  muscular  layer,  occurring  at  a  particular  season 
of  the  year,  characterized  by  coryza,  croupy  or  wheezy  cough,  and 
difficult  respiration. 

Causes.- — ^The  nervous  system  especially  seems  to  predispose  in 
many  cases.  Heredity,  sedentarj^  life,  uric  acid  diathesis,  nasal 
disease,  and  neurotic  constitution  are  important  etiological  factors. 
The  disease  becomes  manifest  in  the  spring  and  autumn,  and  the 
attacks  may  be  brought  about  by  the  inhalation  of  irritating  dusts 
or  vapors,  or  the  pollen  of  grasses,  rye,  corn,  wheat,  or  roses.  The  affec- 
tion is  encountered  most  frequently  in  the  cities  and  in  low  countries. 

Pathology. — A  hyper-sensitiveness  of  the  nasal  mucous  membrane 
is  believed  to  be  the  only  change.  Associated  with  this,  however,  it 
is  rather  common  to  find  hypertrophic  rhinitis,  enlargement  of  the 
inferior  and  middle  turbinated  bones,  nasal  polyps,  and  deflection  of 
the  nasal  septum,  the  relief  of  which  conditions  is  often  followed  by 
cure  of  the  hay  fever. 

Symptoms. — The  affection  begins  with  remarkable  regularity 
about  the  same  time  each  year.  The  attack  begins  with  irritation  of 
the  eyes,  coryza,  and  sneezing,  with  a  clear  watery  nasal  discharge. 
The  congestion  extends  to  the  Eustachian  tube  and  to  the  larynx  and 
bronchial  tubes,  thereby  inducing  a  hoarse,  croupy,  and  wheezing 
cough,  with  difficulty  in  breathing.  The  dyspnea  occurs  in  parox- 
ysms, which  are  often  as  severe  as  those  occurring  in  true  asthmatic 
attacks.  Mild  nervous  depression  is  usually  present.  The  parox- 
ysms remit  after  a  few  days,  to  recur  after  an  interval  of  several  days 
or  weeks,  and  to  be  followed  by  another  remission,  and  so  on  until  the 
season  changes.  The  bronchial  catarrh  persists  during  the  entire 
attack.  Constitutional  symptoms  are  mild  in  the  absence  of 
complications. 

Complications. — Capillary  bronchitis,  congestion  or  edema  of  the 
lungs,  or  pneumonia  may  occur  as  complications. 

Duration. — Unless  a  change  of  climate  is  resorted  to,  paroxysms 
of  hay  fever  continue  more  or  less  severe  for  six,  eight,  or  ten  weeks 
of  the  year,  each  year  the  paroxysms  growing  more  severe. 

Prognosis. — The  affection  never  proves  fatal  in  itself,  but  one  or 
32 


498  HAY   FEVER 

more  of  the  following  sequelae  may  result,  asthma,  chronic  bronchitis, 
or  loss  of  the  special  senses  of  hearing  or  of  smelling. 

Treatment. — There  is  no  specific.  In  those  cases  in  which  nasal 
disease  exists,  considerable  relief  may  be  afforded  by  attention  to  the 
nasal  channels. 

An  attack  of  hay  fever  is  often  prevented  by  a  change  of  climate 
during  the  season  of  the  year  when  the  attacks  are  most  common 
(the  early  autumn) .  Any  of  the  following  locations  may  be  selected : 
White  Mountains,  Catskills,  Adirondacks,  Rocky  Mountains,  or  a 
sea  voyage.  Certain  seaside  resorts,  particularly  Long  Branch, 
Beach  Haven,  Fire  Island,  Nantucket,  and  Mount  Desert  seem  to  be 
especially  beneficial  to  hay  fever  patients. 

The  condition  of  the  general  health  should  receive  very  close  atten- 
tion. Many  patients  are  more  or  less  run  down  and  require  tonics, 
such  as  iron,  strychnine,  arsenic,  quinine,  phosphorus,  etc.,  over  an 
extended  period. 

I^.     Liq.  potass,  arsenit 5j  40.0. 

Syr.  hyphosphos.      q.  s.  ad   giv  120  c.c. 

M.  S. — Two  teaspoonfuls  after  meals. 

I^.     Ext.  belladonnas 

Ext.  cannabis  Indicae. . .  .aa  gr.  j  aa  0.065  gm. 

Camphor gr.  xv  i .  o      gm. 

Quinin.  sulphatis gr.  xx  i  .296  gm. 

M.     Disp.  in  capsul.  No.  vj. 
S. — One  every  three  hours. 

The  digestive  tract  should  be  carefully  examined.  Indigestion 
should  receive  prompt  treatment.  Constipation  should  be  avoided. 
Fruit  and  vegetables  should  form  the  greater  portion  of  the  diet,  and 
animal  foods,  coffee,  and  tea,  should  be  interdicted.  All  the  avenues 
of  excretion  should  be  maintained  in  their  normal  condition.  Fre- 
quent hot  baths,  massage,  electricity,  diuretics,  and  diaphoretics  may 
be  employed  with  this  end  in  view. 

The  attacks  may  apparently  be  aborted  at  times,  by  internal  treat- 
ment. Quinine  sulphate,  gr.  v  (0.3  gm.),  three  times  daily,  adminis- 
tered one  month  before  the  attack  is  expected,  has  been  successful. 
Dover's  powder,  gr.  v  (0.3  gm.),  three  times  daily,  or  the  following 
may  be  used  for  the  same  purpose: 


HAY   FEVER  499 

I^.     Atropinae  sulph gr.  3-^  0.012  gm. 

Morphinae  sulph gr.  M  0.016  gm. 

Strychninae  sulph gr-  M  o  •  008  gm. 

Quininae  hydrochlorid gr-  x  0.65    gm. 

Sodii  arsenat gr.  3^^  o .  01 1  gm. 

M.     Ft.  pil.  No.  XXX. 

S. — One  every  hour  until  dryness,  then  two  or  three  hours 
apart. 

The  following  is  of  benefit  during  the  attack: 

I^.     Ext.  hyoscyami gr.  xij  o .  775  gm. 

Potass,  iodid 5j  40      gm. 

Potass,  bicarb 5ij  8.0      gm. 

Ext.  glycyrrhizae 5iv  150      gm. 

Aquae  anisi. fBivss  136.0      c.c. 

M.  S. — Dessertspoonful  every  four  hours  until  relieved  (Weber). 

Beverley  Robinson  recommends  the  following: 

I^.     Pulveris  camphorae gr.  x  o .  65  gm. 

Oleoresinas  cubebae lUxx  1.3    c.c. 

Glycerini f 5j  4.0    gm. 

Petrolati  liquid! q.  s.  ad  fgss  15.0    c.c. 

M.  S. — Spray  a  little  with  a  glass  atomizer  into  the  nasal 
passages  several  times  a  day,  as  needed. 

The  application  of  tablets  of  cocaine  hydrochloride,  gr.  }i  (o.oii 
gm.),  or  the  same  drug  in  4  per  cent,  solution  every  two  or  three  hours 
will  afford  great  relief.  The  possibility  of  contracting  the  cocaine 
habit  from  this  .treatment  should  not  be  overlooked.  A  much  safer 
plan  is  to  apply  pledgets  of  cotton  soaked  in  a  solution  of  adrenaline 
hydrochloride  (i  to  4000).  Bartholow  advises  the  thorough  applica- 
tion of  quinine  to  the  nares.  The  following  application  is  also  of 
value : 

I^.     Mentholis 3j  4  gm. 

Phenolis 5ss  2  gm. 

Zinci  oxidi 3j  4  gm. 

01.  amygd.  dulcis §jss  45  c.c. 

Cerati  simplicis §  ij  60  gm. 

M.  S. — Apply  thoroughly  to  the  nostrils  every  few  hours. 
Dunbar's  pollantin  has  been  found  beneficial  in  some  cases. 


500  ASTHMA 

ASTHMA 

Synonyms. — Bronchial  asthma;  spasmodic  asthma. 

Definition. — A  paroxysmal,  spasmodic  contraction  of  the  muscular 
layer  surrounding  the  smaller  bronchial  tubes,  and  perhaps  associated 
with  a  tonic  spasm  of  the  diaphragm  and  more  or  less  bronchial 
catarrh;  characterized  by  spasmodic  attacks  of  distressing  expiratory 
dyspnea,  continuing  several  hours,  days,  or  weeks. 

Causes. — The  affection  is  believed  to  be  a  true  neurosis  of  the  res- 
piratory apparatus.  It  may  result  from  peripheral  or  local  disturb- 
ances in  the  nervous  system.  In  many  cases  there  is  a  family  his- 
tory of  asthma,  chorea,  or  epilepsy.  It  is  more  common  in  m^en  than 
in  women,  and  may  occur  at  any  age.  Atmospheric  and  climatic 
changes  may  act  as  causes.  Some  cases  are  of  reflex  origin. 
j>^,^5^Frequently  the  affection  is  due  to  disease  of  the  nasal  or  bronchial 
mucous  membrane,  bronchitis,  emphysema,  chronic  cardiac  disease, 
chronic  gastric  catarrh,  and  malarial  toxemia.  The  inhalation  of 
irritating  substances  such  as  ipecac,  turpentine,  dust,  etc.,  may 
precipitate  an  attack. 

Pathology. — Except  in  the  presence  of  bronchitis  or  other  affection 
there  are  no  structural  changes.  The  attacks  consist  in  spasm  of 
the  muscular  coat  with  vasomotor  turgescence  of  the  mucous  coat 
of  the  bronchi. 

Symptoms. — The  onset  of  the  first  attack  of  asthma  is  abrupt, 
the  succeeding  attacks  being  preceded  by  prodromes,  which  the 
individual  rapidly  learns  to  appreciate — viz.,  coryza,  bronchial  irri- 
tation, thoracic  constriction,  marked  dyspepsia,  or  the  scanty  passage 
of  pale,  limpid  urine  (the  ''hysterical  urine"). 

The  paroxysm  begins,  in  the  majority  of  instances,  in  the  early 
morning  hours  or  during  the  afternoon,  with  a  feeling  of  anguish  and 
constriction  in  the  chest  and  an  intense  desire  for  air.  The  breathing 
is  accompanied  with  loud  wheezing,  the  face  is  flushed,  at  times 
even  cyanosed  and  bathed  in  perspiration?  the  eyes  staring,  the 
eyeballs  protrude,  and  the  muscles  of  the  neck  become  prominent 
as  they  aid  in  the  effort  for  air.  Thy  dyspnea  soon  becomes  so  severe 
that  the  inspiration  is  but  a  gasp,  the  lips  are  pallid,  cyanosis  deepens, 
and  the  patient  feels  as  if  death  were  impending.  Owing  to  the 
tonic  contraction  of  the  smaller  bronchi  the  air  drawn  into  the  alveoli 
escapes  imperfectly,  resulting  in  the  expiratory  dyspnea,  the  emphy- 
sematous chest,  and  the  lowered  position  of  the  diaphragm.     During 


ASTHMA  501 

the  paroxysm  there  is  a  short,  dry  cough,  becoming  more  loose  as 
the  attack  subsides. 

After  some  minutes  or  hours  the  respiration  becomes  easier,  the 
air  in  the  lungs  changes,  the  cyanosis  disappears,  and  gradually 
the  paroxysm  ceases,  the  patient  feeling  exhausted  and  the  chest 
fatigued. 

The  sputum  of  asthma  is  unique.  Early  in  the  paroxysm  it  is 
raised  with  difficulty,  and  takes  the  form  of  rounded  gelatinous 
masses  ("perles"  of  Laennec).  If  these  pellets  are  carefully  examined, 
they  will  be  found  to  consist  of  molds  of  the  smaller  bronchi,  and 
under  the  microscope  show  Ley  den's  crystals  and  Curschmann's 
spirals.  After  a  day  or  two  the  sputum  becomes  muco -purulent, 
and  the  spirals  and  crystals  are  absent. 

The  duration  of  an  attack  varies  from  one  to  many  hours,  or  even 
days.  Instead  of  single  paroxysms,  slight  remissions  may  occur 
at  intervals  of  one,  two,  or  three  hours,  to  be  followed  by  exacerbations 
lasting  from  four  to  six  hours,  continuing  for  a  week  or  two,  prevent- 
ing the  patient  lying  down  or  taking  food. 

Physical  Signs. — Inspection  shows  marked  dyspnea,  with  dis- 
tention of  the  chest. 

Percussion  yields,  during  the  paroxysm,  hyper-resonance  or  a 
vesiculo-tympanic  note  (the  band-box  tone  of  Bamberger)  over  both 
lungs,  due  to  the  retained  air  in  the  alveoli. 

Auscultation  during  the  first  stage  reveals  a  feeble  or  absent  vesicu- 
lar murmur,  with  prolonged  expiration,  associated  With  loud,  wheezing, 
whistling,  sibilant,  and  sonorous  r^es;  as  the  paroxysm  subsides, 
the  vesicular  breathing  becomes  more  noticeable,  and  is  accompanied 
by  moist  rales. 

Prognosis. — The  disease  is  essentially  chronic  and  recovery 
seldom  occurs,  except  when  due  to  reflex  causes  that  may  be  removed. 
The  paroxysms  may  be  relieved  by  treatment.  In  itself  asthma  is 
not  fatal  to  life;  but  if  the  paroxysms  are  frequently  repeated,  there 
results  either  emphysema,  cardiac  dilatation  with  subsequent  dropsy, 
or  even  cerebral  hemorrhage. 

Attacks  of  asthma  frequently  occur  as  a  complication  in  emphysema, 
chronic  bronchitis,  valvular  diseases  of  the  heart,  and  Bright's  disease. 

Treatment. — There  are  two  indications  to  meet — the  relief  of 
the  paroxysm,  and  prevention  of  its  recurrence. 

To  relieve  the  paroxysm,  no  medication  is  so  effective  as  the 
hypodermic  injection    of    morphine  sulphate,    gr.    3^   to   }/i  (o.oii 


502  ASTHMA 

to  0.016. gm.),  combined  with  atropine  sulphate,  gr.  3^100  (0.00065 
gm.).  Chloral,  gr.  x  (0.6  gm.),  in  the  absence  of  cardiac  complica- 
tions is  very  beneficial.  Inhalation  of  chloroform  or  a  few  drops  of 
amyl  nitrite  will  also  serve  to  relieve  the  paroxysm.  Drinking  of 
strong  hot  black  coffee  or  the  administration  of  citrated  caffeine,  gr. 
iij  to  V  (c.2  to  0.3  gm.),  hypodermically,  in  a  cachet,  or  in  solution, 
is  of  great  value. 

The  following  combination  by  hypodermic  injection  is  often  most 
successful  in  relieving  an  attack  of  asthma,  and  particularly  if  com- 
plicated with  cardiac  or  nephritic  disease,  continuing  the  combination 
after  relief,  in  pill  form  or  solution,  at  ordinary  intervals  for  several 
days: 

I^.     Spirit,  glonoini TTlij  0. 12      c.c. 

Strychninae  sulph gr.  J^o  0.0013  gm. 

Morphinae  sulph gr.  3^  0  o  •  003    gm. 

M.  S. — One  dose.     For  hypodermic  use. 

Page  strongly  recommends  sodium  nitrate,  as  in  the  following 
formula : 

I^.     Pulv.  sodii  nitratis gr.  xxiv  i .  6  gm. 

'  Aquse fgj  30.0  c.c. 

M.  S. — Teaspoonful  at  once;  repeat  in  half  an  hour,  once  or 
twice  if  necessary. 

Dr.   Pepper  speaks  highly  of  the  following,  for  the  paroxysm: 

I^.     Ammonii  bromidi Sijss  10  gm. 

Ammonii  chloridi 5jss  6  gm. 

Tinct.  lobelias f  3iij  12  c.c. 

Spt.  setheris  comp f §j  30  c.c. 

Syr.  acaciae .  .  .q.  s.  f  §iv         ad       120  c.c. 

M.  S. — Dessertspoonful  in  water  every  hour  or  two,  diluted. 

The  nauseating  expectorants,  such  as  lobelia,  ipecac,  and  squill, 
are  at  times  of  value.  Fluidextract  of  grindelia,  TTlxx  (1.3  c.c), 
repeated  every  two  hours,  is  sometimes  useful.  Inhalations  of  the 
fumes  of  belladonna,  stramonium,  nitre  paper,  or  ethyl  bromide, 
or  the  use  of  the  various  pastilles  or  cigarettes,  are  of  great  benefit 
in  many  cases.  A  20  per  cent,  solution  of  menthol  and  oxygen  has 
also  been  employed  in  the  same  manner  with  success. 

Among  the  best  drugs  at  our  disposal  are  potassium  iodide,  gr. 
V  to  X  (0.3  to  0.6  gm.),  every  three  hours  either  alone  or  combined 


ASTHMA  503 

with  tincture  of  belladonna,  Vf[v  (0.3  c.c),  or  nitroglycerin,  gr.  ^^00 
to  Hoo  (0.00032  to  0.00065  gin.).  Another  valuable  remedy  is  the 
syrup  of  hydriodic  acid,  3ss  to  3j  (2  to  4  c.c),  every  three  hours, 
diluted.  If  an  attack  is  impending,  it  may  often  be  aborted  by  drink- 
ing freely  of  strong,  black  coffee,  or  by  full  doses  of  the  bromides. 
Bartholow  employs  the  following  in  cigarettes: 

I^.     Sodii  arsenat 5ss  to  j         2  to  4  gm. 

Aquae  destillat g]  30  c.c. 

M.  S. — Moisten  unsized  white  paper,  and  roll  into  cigarettes, 
each  containing  gr.  3^  to  j  of  the  salt.  Two  or  3  of  these  should 
be  inhaled  daily. 

Trousseau's  cigarettes  are: 

I^.     Belladonnae  fol 5j  4-0      gm. 

Stramonii  fol. 

Hyoscyami aa   5  ss  2.0        gm. 

Ext.  opii gr.  iij  o .  194  gm. 

Aquae  laurocerasi q.  s. 

M.  S. — Dissolve  the  opium  in  the  water  and  moisten  the 
leaves  therewith.  When  dry  roll  into  12  cigarettes.  Smoke 
2  a  day. 

Potter  recommends  the  following  prescription: 

I^.     Ext.  stramonii gr.  ij  o .  130  gm. 

Potass,  iodid 5jss  6.0      gm. 

Ammonii  carbonat 5j  4-0      gm. 

Tr.  lobeliae 5 jss  6.0      c.c. 

Aquae  chloroformi.  .q.  s.  ad   Bviij  480.0      c.c. 
M.  S. — Tablespoonful  every  six  hours. 

The  following  combination  may  be  of  service : 

I^.     Morphin.  sulphat gr.  ss  0.032  gm. 

Fluidextract.  belladonnae  . .    TTlxxxij  2.     o  c.c. 

Fluidextract.  grindeliae. .  .  .   f  3ij  8.0  c.c. 

Spt.  etheris  comp f  5iv  15.     o  c.c. 

Syrupi q.  s.  ad  f  5ij  60.     o  c.c. 

M.  S. — Teaspoonful  as  the  occasion  requires. 

During  the  interval  between  the  attacks,  the  nasal  mucous  mem- 
brane should  be  carefully  examined  and  in  the  presence  of  morbid 
conditions  should  receive  appropriate  treatment.     The  condition  of 


504  EMPHYSEMA 

the  heart  and  lungs  should  likewise  be  ascertained.  The  digestive 
tract  should  also  receive  attention.  The  various  reflex  conditions 
that  may  induce  the  paroxysms  should  be  removed.  Dry  climate  is 
usually  most  beneficial.  The  long-continued  administration  of  po- 
tassium iodide  and  arsenic  is  of  special  value.  As  additional  aids  may 
be  mentioned  systematic  exercise  short  of  fatigue,  bathing,  regulated 
diet,  and,  when  possible,  a  change  of  climate. 

DISEASES  OF  THE  LUNGS 

EMPHYSEMA 

S3mon3mi. — Vesicular  emphysema. 

Definition. — Dilatation  of  or  increase  in  the  size  and  capacity  of  the 
air- vesicles,  characterized  by  enlargement  or  distention  of  the  lungs, 
difficulty  of  breathing,  especially  on  exertion,  and  associated  sooner 
or  later  with  dilatation  of  the  heart. 

Causes. — The  predisposing  cause  of  emphysema  is  a  hereditary 
nutritive  derangement  of  the  lung-structure,  often  associated  with  a 
rigid  enlargement  of  the  thorax. 

The  exciting  cause  is  either  too  forcible  and  long-continued  inspir- 
ation— the  theory  of  inspiration — or  the  excessive  mechanical  disten- 
tion of  the  vesicular  walls  by  forced  expiration — the  theory  of  expiration. 
But  for  either  of  these  theories  to  be  operative  the  lung-structure  must 
be  congenitally  weak,  for  if  violent  respiratory  efforts  alone  were  the 
essential  factor,  the  disease  would  be  much  more  frequent. 

What  is  known  as  vicarious  or  compensatory  emphysema  is  a  disten- 
tion of  the  air-cells  of  the  healthy  portion  of  the  lung,  some  other  part 
being  the  seat  of  consolidation. 

Interlobular  emphysema  is  the  presence  of  air  in  the  spaces  between 
the  lobules  of  the  lungs  underneath  the  pulmonary  pleura. 

Ordinary  vesicular  emphysema  is  known  also  as  pseudo-hypertrophic 
emphysema  on  account  of  the  increase  in  the  capacity  of  the  vesicles, 
due  to  distention.  The  walls  of  the  vesicles  are  atrophic  to  a  greater 
or  less  extent. 

Senile  emphysema  is  another  variety;  often  termed  ''small-lunged 
emphysema."  There  is  true  atrophy  of  the  pulmonary  vesicles, 
although  their  capacity  may  be  relatively  increased. 

Pathological  Anatomy. — The  situation  of  vesicular  emphysema  is, 
in  the  majority  of  cases,  the  superior  portions  of  the  chest,  and  is  more 
marked  on  the  left  side  than  on  the  right. 


EMPHYSEMA  505 

An  emphysematous  lung  feels  remarkably  soft  to  the  touch,  and 
upon  cutting,  a  dull,  creaking  sound  is  barely  perceptible.  It  is  of 
a  pale-red  color ;  the  vesicular  walls  are  thinner  and  slighter ;  the  vesicles 
are  greatly  enlarged,  sometimes  to  the  size  of  a  pea  or  bean,  and  have 
an  irregular  shape,  and  traversing  most  of  these  large  sacs  (dilated 
vesicles)  a  few  delicate  bands,  the  remains  of  the  lacerated  interal- 
veolar  septa,  are  visible.  With  the  destruction  of  the  septa  many  of 
the  capillaries  are  destroyed,  leaving  the  emphysematous  tissue  re- 
markably bloodless  and  dry.  In  consequence  of  the  destruction  of  so 
many  of  the  capillaries,  the  obstruction  to  the  pulmonary  circulation 
becomes  so  great  that  the  pulmonary  artery  and  right  cavities  of  the 
heart  are  greatly  distended;  finally  the  muscular  tissue  of  the  heart 
undergoes  granular,  followed  by  fatty,  degeneration.  The  distention 
of  the  veins  results  in  a  general  venous  stasis,  with  nutmeg  liver,  con- 
gested kidneys,  and  gastro-intestinal  catarrh. 

S3rmptoms. — The  disease  is  often  not  suspected  until  it  is  well  de- 
veloped. The  chief  symptoms  of  vesicular  emphysema  are  difficulty 
of  breathing  (dyspnea),  greatly  aggravated  on  exertion;  more  or  less 
cough,  the  result  of  an  attending  bronchitis,  and  the  various  symp- 
toms resulting  from  dilatation  of  the  heart,  particularly  cyanosis 
without  marked  distress.  The  discomfort  of  the  patient  is  often  in- 
creased by  paroxysms  of  asthma. 

Physical  Signs. — Inspection. — The  shoulders  are  rounded,  the 
intercostal  spaces  widened,  and  the  vertical  diameter  elongated,  with 
circumscribed  prominences  between  the  clavicles  and  nipples,  often 
increased  by  the  act  of  coughing — the  peculiar  "barrel-shaped" 
chest,  characteristic  of  this  disease.  The  character  of  the  respiratory 
movements  is  marked,  there  being  but  slight  movement  observed  on 
forcible  respiration,  the  chest  having  the  constant  appearance  of  a  full 
inspiration. 

Palpation. — The  vocal  fremitus  is  diminished,  and  the  cardiac 
impulse  depressed  and  nearer  to  the  sternum. 

Percussion. — The  resonance  is  increased  (hyper-resonant)  over 
all  the  emphysematous  portions,  and,  if  the  whole  lung  be  involved, 
extends  to  the  seventh  or  eighth  rib  anteriorly  and  to  the  twelfth 
rib  posteriorly.  The  hepatic  dullness  may  not  begin  until  the 
inferior  margin  of  the  ribs  is  reached;  the  cardiac  dullness  is  lessened, 
on  account  of  the  emphysematous  lung  nearly  covering  the  heart. 

Auscultation. — The  vesicular  murmur  is  weakened,  and  in  pro- 
nounced  cases   almost   absent.     If   bronchitis   be   present,   the   in- 


5o6  EMPHYSEMA 

spiratory  sound  may  be  rough  or  sibilant  in  character,  but  its  duration 
is  always  shortened.  Expiration  is  always  prolonged,  and  if  bronchi- 
tis be  present,  may  be  associated  with  more  or  less  pronounced  moist 
or  bubbling  rales.  The  first  sound  of  the  heart  is  lessened  in  in- 
tensity and  duration,  the  second  sound  being  sharply  accentuated. 

Diagnosis. — Bronchitis  is  distinguished  from  emphysema  by  the 
absence  of  dyspnea,  hyper-resonance  of  the  chest,  changes  in  its 
shape,  size,  and  movements,  and  the  disturbance  of  the  circulation. 

Spasmodic  asthma,  by  the  paroxysmal  character  of  the  affection, 
emphysema  being  a  permanent  malady,  with  attacks  of  asthma. 

Cardiac  diseases  due  to  other  causes  than  emphysema  do  not 
have  the  characteristic  physical  signs  of  that  affection. 

Prognosis. — Vesicular  emphysema  is  essentially  a  chronic  disease. 
In  itself  it  rarely  proves  fatal,  but  if  aggravated  from  any  cause, 
or  if  associated  with  frequent  or  prolonged  asthmatic  paroxysms, 
the  cardiac  changes  are  hastened,  and  general  dropsy  supervenes, 
death  occurring  from  exhaustion  or,  more  commonly,  as  the  result 
of  intercurrent  attacks  of  pneumonia. 

Treatment. — It  being  impossible  to  restore  the  altered  lung- 
structure,  the  indications  for  treatment  are  to  relieve  the  symptoms 
and  to  endeavor  to  prevent  its  further  progress. 

For  the  relief  of  the  asthmatic  paroxysms,  morphine  sulphate, 
combined  with  atropine  sulphate,  may  be  used  hypodermically. 
Citrated  caffeine,  gr.  ij  to  v  (0.13  to  0.3  gm.),  alone  or  in  combination 
with  nitroglycerin,  strychnine,  or  morphine,  potassium  iodide,  or 
inhalations  of  oxygen,  may  be  employed  for  the  same  purpose. 

For  the  attacks  of  bronchial  catarrh  the  following  is  of  value: 

I^.     Ammonii  chloridi 5ij  8  gm. 

Tinct.  hyoscyami f  5iv  15  c.c. 

Glycerini f §j  30  c.c. 

Syr.  prun.  virg q.  s.  ad  f  §iv  ad         120  c.^. 

M.  S. — Half  tablespoonful  every  few  hours,  well  diluted. 
To  prevent  the  progress  of  the  affection,  remove  the  bronchial  catarrh, 
relieve  the  difficulty  of  breathing,  and  strengthen  the  cardiac  action; 
no  one  combination  seems  comparable  with  the  following  for  this 
purpose : 

I^.     Potassii  iodidi gr.  v  0.3      gm. 

Strychninae  sulph gr.  K2  0.002  gm. 

Liq.  potassii  arsenit TTlv  o .  3      c.c. 

Aq.  lauro-cerasi f3j  40      c.c. 

M.  S. — Four  times  a  day,  well  diluted. 


HEMOPTYSIS  507 

But  of  all  means  hitherto  proposed  for  the  relief  of  emphysema, 
nothing  has  approached  the  inhalation  of  compressed  air  by  means 
of  the  apparatus  of  Waldenberg.  Unfortunately  the  apparatus  is 
costly,  and  the  method  of  application  is  difficult.  For  attacks  of 
cyanosis  a  free  venesection  often  saves  life,  combined  with  and  fol- 
lowed by  full  doses  of  spirit  of  glonoin  (nitroglycerin) .  The  dropsy 
arising  from  failure  of  the  heart  to  compensate  for  the  circulatory 
derangement  in  the  lungs,  may  be  relieved  for  a  time,  by  the  use  ol 
digitalis  and  strychnine  sulphate,  or  citrated  caffeine,  the  last  two 
being  cardiac  and  respiratory  tonics  and  stimulants,  and  the  caffeine 
a  diuretic  also. 

HEMOPTYSIS 

Synonyms. — Bronchial  hemorrhage;  bronchopulmonary  hemor- 
rhage; bronchorrhagia. 

Definition. — The  expectoration  of  pure  or  unmixed  blood,  usually 
of  a  bright-red  color,  following  the  act  of  coughing. 

Causes. — In  the  majority  of  cases,  it  is  the  result  of  tuberculous 
deposition  in  the  walls  of  the  minute  bronchial  arteries,  excessive 
cardiac  action,  bronchial  congestion,  or  excessive  bodily  exertion, 
straining,  lifting,  or  running.  It  may  also  be  due  to  traumatism, 
pulmonary  congestion,  gangrene,  infarction,  or  cancer,  ulceration 
of  any  portion  of  the  respiratory  tract,  or  to  rupture  of  an  aneurysm. 
In  very  rare  instances  it  may  be  produced  in  the  course  of  hemophilia, 
purpura,  or  scurvy,  and  may  be  an  example  of  vicarious  menstruation. 
Cases  may  occasionally  be  observed  in  which  no  cause  can  be  detected. 

Pathological  Anatomy. — Hemoptysis  rarely  causes  death  in  itself, 
so  that  few  opportunities  for  observing  postmortem  appearances 
are  obtained,  and  when  they  do  occur,  the  location  of  the  hemorrhage 
is  seldom  found.  The  air-passages  are  more  or  less  filled  with  clotted 
blood;  the  mucous  membrane  is  swollen,  and  of  a  dark -red  color; 
rarely,  pale  and  bloodless.  The  air-cells  contain  blood  clots,  or  are 
distended  with  air,  the  bronchi  being  filled  with  clots,  preventing 
its  escape.  Unless  the  clots  are  rapidly  removed  by  expectoration  or 
absorption,  a  secondary  inflammation  develops  around  them. 

Symptoms. — "Spitting  of  blood"  occurs  suddenly;  rarely,  it  is 
preceded  by  epistaxis,  cardiac  palpitation,  and  some  difficulty  of 
breathing.  It  begins  with  a  sensation  of  warmth  under  the  sternum, 
tickling  in  the  throat,  a  sweetish  taste  in  the  mouth,  an  attempt  to 
remove  which  by  the  act  of  coughing  is  followed  by  a  warm,  saltish. 


5o8  HEMOPTYSIS 

bright-red,  frothy  liquid  gushing  from  the  mouth  and  nose.  The 
blood  is  alkaline  in  reaction  and  mixed  with  air  and  mucus.  The 
quantity  of  blood  raised  varies  from  an  ounce  to  a  pint.  The  appear- 
ance of  the  blood  depresses  the  individual,  he  becoming  pale,  tremu- 
lous, often  fainting.  The  attack  may  subside  within  half  an  hour  to 
several  hours,  returning  for  several  days,  in  the  meantime  the  expec- 
toration being  either  bloody  or  streaked  with  blood.  A  slight  febrile 
reaction,  with  chest  pains,  supervenes  upon  the  hemorrhage,  the  result 
of  the  inflammation  at  the  site  of  the  bleeding,  which  soon  subsides, 
except  when  blood  clots  develop  a  secondary  pneumonia,  which  may 
undergo  cheesy  metamorphosis. 

Auscultation  reveals  the  presence  of  coarse,  bubbling  rales  in  cir- 
cumscribed areas  of  the  chest. 

Diagnosis. — From  epistaxis,  or  hemorrhage  from  the  posterior 
nares,  it  is  distinguished  by  the  absence  of  air-bubbles  and  an  inspec- 
tion of  the  fauces  and  the  nasal  cavities. 

Hematemesis,  or  hemorrhage  from  the  stomach,  differs  from  hem- 
optysis in  the  blood  being  vomited  instead  of  expectorated,  of  a  dark 
color,  clotted,  mixed  with  the  acid  contents  of  the  stomach,  followed 
with  black,  tar-like  stools,  and  the  absence  of  rales  in  the  chest  (and 
seepage  237). 

Exceptions  to  the  above  occur  when  the  blood  from  the  lungs  is 
first  swallowed  and  afterward  raised  by  vomiting,  or  when  the  hemor- 
rhage in  the  stomach  is  caused  by  the  erosion  of  a  large  artery,  the 
result  of  ulcer  of  the  stomach ;  in  these  cases,  however,  the  raising  of 
blood  is  preceded  by  epigastric  pain  and  the  blood  is  not  frothy. 

Prognosis. — Hemoptysis,  in  itself,  rarely  terminates  fatally,  except 
in  advanced  phthisis  and  aneurysm,  although  causing  much  depres- 
sion; the  patient  rapidly  recovers,  unless  secondary  pneumonia  results. 

Treatment. — Perfect  rest  in  bed,  with  the  head  and  shoulders  ele- 
vated and  absolute  quiet  is  essential.  The  diet  should  be  bland  and 
unirritating,  and  the  drinks  cool,  the  patient  being  allowed  to  slowly 
swallow  small  particles  of  ice.  An  ice-bag  placed  over  the  chest,  if  it 
does  not  cause  chilliness,  is  sometimes  of  value.  Common  salt, 
slowly  dissolved  in  the  mouth,  is  a  popular  remedy,  and  while  of  little 
or  no  benefit,  serves  to  occupy  the  attention  of  the  patient  and  friends 
until  medical  advice  is  obtained.  The  hypodermic  injection  of  mor- 
phine sulphate,  gr.  3^  (0.016  gm.),  combined  with  atropine  sulphate, 
gr.  %Q  (o.ooi  gm.),  will  usually  control  a  hemorrhage  immediately. 
The  official  spirit  of  nitroglycerin  in  half  minim  to  minim  doses  every 


CONGESTION   OF   THE    LUNGS  509 

half  hour,  often  promptly  checks  the  hemorrhage.  The  intrapul- 
monary  pressure  may  be  lowered  and  the  flow  of  blood  consequently 
lessened  by  the  application  of  firm  ligatures  to  the  limbs.  In  pro- 
tracted cases,  saline  purgation  may  be  of  benefit.  The  following 
prescription  may  also  be  employed: 

I^.     Acidi  gallici gr.  xv  i  .0  gm. 

Acidi  sulphurici  dil lUx  0.6  c.c. 

Aquae  cinnamomi f  3iv  15  o  c.c. 

M.  S. — One  dose;  to  be  given  every  fifteen  or  twenty  minutes. 

Other  drugs,  such  as  fluidextract  of  matico,  f  5j  (4  c.c),  fluidex- 
tract  of  hamamelis, TTLxx  to  f  3j  (i-3  to  4  c.c),  alum,  gr.  xx  (1.3  gm.), 
gallic  acid,  gr.  v  to  x  (0.3  to  0.6  gm.),  and  oil  of  turpentine,  T([v  to  xv 
(0.3  to  I  c.c),  frequently  repeated,  have  been  used  with  success. 

The  hypodermic  injection  of  ergotine,  gr.  x  to  xxx  (0.6  to  2  gm.), 
and  the  internal  administration  of  fluidextract  of  ergot,  3ss  to  j  (2  to 
4  c.c),  have  also  been  recommended,  but  they  are  harmful  at  times. 

Inhalations,  by  means  of  the  steam  atomizer,  of  either  Monsel's 
solution,  or  tincture  of  the  chloride  of  iron,  may  be  of  value  when 
other  means  have  failed.  DaCosta  advises,  for  frequent  small  hem- 
orrhages recurring  daily,  a  combination  of  cupric  sulphate,  gr.  H2 
(0.005  gn^-)>  and  extract  of  opium,  gr.  3^2  (0-005  giii-)>  repeated  as  the 
occasion  requires. 

Bartholow  employs  the  following: 

I^.     Plumbi  acetat gr.  xx  1.3      gm. 

Pulv.  digitalis gr.  x  o .  65    gm. 

Pulv.  opii :  .  .  .    gr.  V  o  .  324  gm. 

M.     Ft.  pil.  No.  X. 

S. — One  every  four  hours. 

The  following  formula  may  be  used  at  times: 

I^.     Aluminis 5j  4-0  gm. 

Sacch.  alb 3  ss  2.0  gm. 

Pulv.  ipecac,  comp gr.  xx  1.3  gm. 

M.     Ft.  pulv.  No.  vj. 

S. — One  powder  every  two  hours  (Skoda). 

CONGESTION    OF   THE   LUNGS 

Synonyms. — Pulmonary  engorgement;  hypostatic  congestion. 
Definition. — An  increase  in,  or  abnormal  fullness  of,  the  capillaries 


510  CONGESTION    OF    THE    LUNGS 

of  the  air-cells;  active  congestion  when  the  result  of  an  accelerated 
circulation;  passive  congestion  when  caused  by  an  impeded  outflow 
from  the  capillaries. 

Causes. — Active. — Increased  cardiac  action;  overexertion;  alcoholic 
excesses;  mental  excitement;  inhalation  of  cold  or  hot  air. 

Passive. — Obstruction  to  the  return  circulation.  Dilated  heart; 
valvular  diseases;  low  fevers  (hypostatic  congestion) ;  Bright's  disease. 

Pathology. — The  congested,  or  engorged  lung,  has  a  bloated,  dark- 
red  appearance;  its  vessels  are  distended  to  the  uttermost,  the  tissues 
succulent  and  relaxed,  blood  flowing  freely  over  the  cut  surface;  a 
bloody,  frothy  liquid  is  present  in  the  bronchi,  and  the  alveolar  walls 
are  so  much  swollen  that  the  condensed  lung  shows  scarcely  any  indi- 
cation of  its  cellular  structure,  resembling  the  tissue  of  the  spleen 
{splenification) . 

Symptoms. — Active  congestion  precedes  inflammatory  pulmonary 
conditions,  and  is  characterized  by  rapidly  developing  thoracic 
distress  and  difficult  breathing,  flushed  face,  strong,  full  pulse,  throb- 
bing carotids,  cardiac  palpitation,  congested  eyes,  and  a  short,  dry 
cough,  followed  by  scanty,  frothy  expectoration,  slightly  streaked 
with  blood.  The  presence  of  fever  indicates  subsequent  inflammation 
or  pneumonia. 

Passive  congestion  develops  slowly  with  difficulty  in  breathing, 
blueness  of  the  body-surface,  and  an  almost  continuous  hacking  cough, 
followed  by  scanty,  blood-streaked,  expectoration. 

Physical  Signs. — Percussion  shows  the  resonance  of  the  lungs 
slightly  diminished,  the  quality  of  the  sound  being  somewhat  tym- 
panitic. Auscultation  reveals  diminution  of  the  vesicular  murmur 
and  the  presence  of  subcrepitant  rales. 

Duration. — Active  congestion  lasts  from  three  to  five  days,  ter- 
minating in  resolution,  hemorrhage,  or  pneumonia.  The  onset  may 
be  so  severe  and  overwhelming  that  death  rapidly  supervenes.  Pas- 
sive congestion  develops  slowly  and  is  subject  to  many  and  great 
variations,  depending  on  the  cause. 

Diagnosis. — Active  congestion  of  the  lungs  cannot  be  distinguished 
from  the  stage  of  engorgement  of  a  true  pneumonia. 

Prognosis. — An  acute  congestion  of  the  lungs  may  prove  fatal 
within  a  few  hours,  but  under  prompt  treatment  it  generally  termi- 
nates favorably. 

The  passive  form  is  controlled  entirely  by  the  cause. 

Treatment. — In  active  congestion  in  strong  and  vigorous  individuals, 


.  EDEMA    OF    THE    LUNGS  511 

ice-bags  and  wet  cups  applied  to  the  chest,  or  venesection  can  be 
recommended.  The  internal  administration  of  tincture  of  aconite, 
lUijss  to  V  (0.15  to  0.3  c.c),  every  half  hour,  and  saline  cathartics 
is  also  beneficial  in  such  cases.  Rest  in  bed  is  essential  in  all  cases. 
In  passive  congestion  in  addition  to  treatment  directed  toward  the 
underlying  cause,  there  should  be  dry  or  wet  cups  applied  to  the  chest, 
and  hydragogue  cathartics,  digitalis,  and  strychnine  administered. 
If  much  depression  is  present,  stimulants  are  indicated. 

EDEMA  OF  THE  LUNGS 

S3monym. — Pulmonary  edema. 

Definition. — An  exudation  of  serum  into  the  pulmonary  inter- 
stitial tissue  and  the  alveoli  of  the  lungs;  characterized  by  dyspnea, 
cough,  and  a  frothy,  blood-streaked  expectoration. 

Causes. — Pulmonary  edema  is  the  result  of  stasis,  occurring  when 
the  outflow  of  venous  blood  in  the  lung  meets  an  obstacle  that 
cannot  be  overcome  by  the  right  ventricle,  as  in  cardiac  diseases 
in  which  the  left  ventricle  fails,  Bright's  disease,  and  alcoholic  ex- 
cesses, causing  cardiac  depression.  It  is  also  seen  in  pernicious  ane- 
mia; and  it  may  be  a  sequel  to  other  lung  inflammations. 

Pathological  Anatomy. — The  lung-tissue  is  swollen,  and  does  not 
collapse  when  the  chest  is  opened.  The  elasticity  of  the  tissue  has 
disappeared,  and  it  pits  upon  pressure.  If  following  acute  congestion 
of  the  lungs,  the  color  is  red;  if  a  symptom  of  a  general  dropsy,  its 
color  is  pale.  On  cutting  into  the  edematous  spots,  an  enormous 
quantity  of  albuminous  fluid,  sometimes  clear,  at  other  times  of  a 
red  color,  mixed  more  or  less  with  blood,  flows  over  the  cut  surface. 
The  liquid  is  filled  with  bubbles,  is  frothy,  from  being  copiously 
mixed  with  air,  providing  the  air  cells  have  not  been  entirely  filled 
with  serum,  thereby  excluding  the  air. 

Symptoms. — The  preeminent  symptom  is  dyspnea,  the  breathing 
being  hurried,  labored,  and  rattling,  all  the  accessory  muscles  of 
respiration  being  called  into  action.  The  sense  of  oppression  and 
anxiety  is  extreme.  There  is  also  a  constant,  harassing,  short  cough, 
and  the  expectoration  is  a  blood-streaked,  frothy  mucus.  The  action 
of  the  heart  may  be  tremulous  or  feeble.  The  face  is  at  first  flushed, 
but  as  the  left  ventricle  fails,  or  if  the  effusion  into  air-cells  be 
sufficient  to  prevent  the  entrance  of  air,  symptoms  of  cyanosis  rapidly 
supervene,  the  pulse  becoming  feeble,  the  surface  cold,  the  breathing 


512  BRONCHOPNEUMONIA 

shallow  and  hiirried,  and  the  cough  suppressed,  stupor  replacing  the 
restlessness,  soon  deepening  into  coma. 

Physical  Signs. — Percussion  reveals  no  change  in  the  percussion - 
note  in  the  absence  of  other  lung  diseases  except  slight  impairment. 
Auscultation  demonstrates  weak  breath  sounds,  and  subcrepitant 
and  bubbling  rales. 

Diagnosis. — Acute  pneiimonia  in  the  earlier  stages  is  the  only 
condition  likely  to  be  confounded  with  edema  of  the  lungs,  but  as 
the  two  diseases  progress,  the  picture  of  pulmonary  edema  is  so 
characteristic  that  it  cannot  be  mistaken. 

Prognosis. — Grave,  and  particularly  if  occurring  in  pneumonia, 
cardiac,  or  Bright's  disease.  In  the  majority  of  instances  it  is  a 
terminal  symptom  coming  on  in  all  forms  of  acute  and  chronic 
diseases. 

Treatment. — As  a  rule  remedies  are  useless.  The  indication  is  to 
maintain  the  heart,  and  this  may  be  accomplished  by  the  hypodermic 
injection  of  atropine  sulphate,  gr.  3^o  (o.ooi  gm.),  repeated  as 
necessary,  strychnin  sulphate,  gr.  ^^4  (0.0035  g^^-)?  repeated  every 
half -hour,  citrated  caffeine,  gr.  iij  to  v  (0.2  to  0.3  gm.),  sparteine  sul- 
phate, gr.  j  to  ij  (0.065  to  0.13  gm.),  every  hour  or  two,  or  digitalin,  gr. 
y&Q  to  3^0  (0.00 1  to  0.002  gm.),  every  two  hours.  Two  or  more 
of  these  drugs  may  be  combined  with  advantage.  Occasionally  re- 
lief follows  a  free  venesection  or  the  application  of  wet  cups  to  the 
chest.  Purgation  with  hydragogue  cathartics  is  a  useful  adjunct 
to  the  treatment.  Alcoholic  stimulants  and  ammonia  are  also 
valuable.  Counterirritation,  ice  poultices,  hot  foot-baths,  diuretics, 
and  inhalations  of  oxygen  may  be  employed. 

BRONCHOPNEUMONIA 

Synonyms. — Catarrhal  pneumonia;  lobular  pneumonia;  capillary 
bronchitis. 

Definition. — An  acute  catarrhal  inflammation  of  the  bronchioles 
and  alveoli  of  the  lungs,  characterized  by  fever,  cough,  dyspnea, 
copious  expectoration,  and  great  depression. 

Causes. — It  may  be  due  to  an  extension  downward  of  a  bronchial 
catarrh,  or  it  may  follow  one  of  the  infectious  fevers,  especially 
measles,  influenza,  and  whooping  cough.  Persons  of  the  rachitic 
or  scrofulous  diathesis,  in  whom  there  is  a  greater  irritability  of  the 
epithelial  elements,  are  particularly  predisposed  to  this  form  of  pneu- 
monia on  slight  exposure.     It  may  also  be  due  to  influenza  or  heart 


BRONCHOPNEUMONIA  513 

disease.  The  affection  is  observed  most  frequently  in  childhood  and 
old  age.  The  inspiration  of  particles  of  food  and  mucus,  such  as 
occurs  in  palsies,  uremia,  last  stages  of  low  diseases,  etc.,  induces 
pneumonia  of  the  catarrhal  type  (aspiration  or  deglutition  pneumonia) . 

The  exciting  cause  is  a  microorganism  or  group  of  microorganisms. 
Mixed  infection  is  the  common  condition.  The  organisms  found 
with  greatest  frequency  are  the  micrococcus  lanceolatus,  the 
streptococcus  pyogenes,  the  staphylococcus  aureus  and  albus,  and 
Friedlander's  bacillus.  In  some  cases,  the  colon  bacillus,  the 
typhoid  bacillus,  Klebs-Loffler  bacillus,  or  the  bacillus  of  pneumonia 
may  be  demonstrated. 

Pathological  Anatomy. — The  earliest  change  is  hyperemia  of  the 
mucous  membrane  of  the  bronchi,  extending  to  the  connective  tissue 
of  the  bronchioles  and  accompanying  arterioles  and  to  the  alveoli, 
with  swelling  and  succulence  of  these  tissues,  accompanied  by  an 
abnormal  secretion  and  an  immense  production,  of  young  cells  from 
the  proliferation  of  the  bronchial  and  alveolar  epithelium,  admixed 
with  a  yellowish,  creamy,  mucoid  material,  which  blocks  up  the 
bronchioles  and  air-cells. 

Both  lungs  are  involved,  and  on  section  scattered  areas  of  con- 
solidation are  observed  surrounding  the  finer  bronchioles.  Collapsed 
areas  may  be  noticed  in  addition,  due  to  obstruction  of  the  bronchi. 
The  terminal  bronchi  are  found  filled  with  a  purulent  exudate.  This 
exudate  and  the  infiltrate  in  the  lung-tissue  are  made  up  of  desqua- 
mated epithelium  and  leukocytes. 

The  affected  parts  first  have  a  reddish-gray,  soon  changing  to  a 
yellowish-gray,  color,  due  to  the  rapid  metamorphosis  of  the  newly 
developed  cells.  If  the  fatty  change  be  completed,  absorption 
takes  place  and  the  consolidation  is  removed;  if  it  remains  incomplete, 
the  cells  atrophy,  the  little  mass  becoming  caseous,  and  the  disease 
passes  into  a  chronic  state. 

The  bronchial  tubes  also  participate  in  the  disease;  the  walls 
become  thickened  from  a  hyperplasia  of  the  connective  tissue  {peri- 
bronchitis) ,  and  their  caliber  is  often  increased. 

Symptoms. — Catarrhal  pneumonia  begins  as  a  catarrhal  bron- 
chitis.    It  may  be  either  acute,  subacute,  or  chronic  in  its  course. 

Acute  variety:  Its  onset  is  announced  by  a  gradual  rise  of  tem- 
perature to  102°  to  i03°F.,  the  febrile  phenomena  assuming  a  typical 
remittent  character,  with  rapid,  laborious,  and  shallow  breathing, 
as  shown  by  the  widely  dilated  nare^  and  violent  action  of  all  the 
33 


514  BRONCHOPNEUMONIA 

accessory  muscles,  while  the  insufficient  distention  of  the  lungs  is 
shown  by  the  great  recession  of  the  lower  part  of  the  chest-walls  and 
sinking  in  of  the  intercostal  spaces.  The  inspiration  is  short  and 
imperfect,  the  expiration  noisy  and  prolonged;  the  pulse  is  frequent, 
100  to  200  or  more,  and  somewhat  compressible;  the  cough,  which 
during  bronchitis  was  loose,  now  becomes  short,  hacking,  dry,  and 
painful,  soon  followed  by  more  or  less  copious  muco-purulent  expec- 
toration; the  appetite  is  impaired,  the  bowels  somewhat  loose,  the 
urine  scanty  and  high-colored,  and  the  surface  frequently  covered 
with  a  more  or  less  profuse  perspiration. 

The  subacute  and  chronic  varieties  have  the  same  general  symptoms, 
but  the  duration  is  longer  and  the  exhaustion  greater. 

The  progress  of  catarrhal  pneumonia  is  sometimes,  although  not 
often,  a  very  acute  one.  The  disease  may  prove  fatal  in  a  few  days, 
especially  if  it  attacks  feeble  children;  in  such  cases  the  countenance 
becomes  pale  and  livid,  the  lips  bluish,  the  eyes  dull,  and  a  restlessness 
supervenes,  giving  place  to  apathy  and  a  continually  augmented 
somnolence. 

Resolution,  when  it  occurs,  is  by  lysis,  several  weeks  elapsing 
before  complete  recovery. 

Physical  Signs. — Percussion  yields  dullness  in  scattered  areas  over 
both  lungs,  the  intervening  healthy  lung  often  giving  a  more  or  less 
hollow  or  tympanitic  note. 

Auscultation  reveals  vesiculo-bronchial  breathing,  changing  to 
moist  bronchial  breathing,  associated  with  small  bubbling  (sub- 
crepitant)  rMes.  As  the  disease  progresses  toward  resolution,  the 
rMes  become  larger  (larger  bubbling)  and  more  numerous.  If 
pneumonic  phthisis  result,  physical  signs  indicative  of  that  condition 
are  soon  evident. 

Sequelae. — Attacks  of  catarrhal]  pneumonia  complicated  with 
atelectasis  or  collapse  of  the  lobules,  when  recovery  occurs,  are  fol- 
lowed by  emphysema  of  the  lungs. 

If  the  catarrhal  products  which  fill  the  alveoli  and  bronchioles 
and  intervening  connective  tissue  do  not  rapidly  undergo  complete 
fatty  metamorphosis  and  consequent  absorption,  pneumonic  phthisis 
results. 

Diagnosis. — Ordinary  bronchial  catarrh  differs  from  broncho- 
pneumonia by  the  absence  of  dyspnea,  fever,  and  dullness  on  per- 
cussion, and  the  presence  of  the  large  bubbling  rales,  and  also  by  the 
subsequent  history  of  the  two  affections. 


BRONCHOPNEUMONIA  515 

Lobar  pneumonia  is  a  unilateral  disease;  bronchopneumonia  is 
bilateral  and  diffused  over  both  lungs — the  former  a  self -limited 
disease,  the  latter  having  no  fixed  duration.  Lobar  pneumonia  is 
characterized  by  acute  onset,  high  fever  terminating  usually  by  crisis 
within  ten  days,  and  distinct  physical  signs,  indicating  uniform 
consolidation. 

Acute  tuberculosis  at  its  onset  is  characterized  by  the  presence  of 
a  capillary  bronchitis,  a  differentiation  being  possible  only  by  a 
study  of  the  clinical  history  and  course  of  the  two  maladies,  and  the 
presence  of  the  tubercle  bacilli  in  the  former. 

Edema  of  the  lungs  is  a  bilateral  disease  associated  with  a  short, 
dry  cough,  and  dyspnea,  but  lacks  the  previous  catarrhal  history 
and  high  temperature  of  catarrhal  pneumonia. 

Prognosis. — Fully  one-half  of  the  cases  of  true  catarrhal  pneu- 
monia terminate  fatally.  The  prognosis  must  be  guarded  in  scrofu- 
lous or  rachitic  subjects,  or  those  enfeebled  by  other  diseases,  for, 
unless  prompt  resolution  can  be  effected,  it  will  terminate  fatally 
early,  or  develop  pneumonic  phthisis. 

Treatment. — Confinement  to  bed  is  paramount,  but  the  position 
of  the  patient  is  to  be  frequently  changed.  The  diet  must  be  of 
the  most  nutritious  character,  administered  at  frequent  intervals; 
milk,  eggs,  chicken,  beef,  mutton  and  oyster  broths  are  the  most 
suitable  articles.  The  steady  use  of  brandy  or  whiskey  throughout 
the  attack  is  of  importance,  regulating  the  amount  by  the  age  of  the 
patient  and  the  severity  of  the  attack. 

Locally,  a  weak  mustard  plaster  followed  with  a  cotton-batting 
jacket  is  valuable.  Poultices  are  of  little  use.  The  febrile  symptoms 
and  early  cough  are  often  modified  by  the  following  mixture : 

I^.     Potassii  citratis 5vj  24  gm. 

Spt.  astheris  nitrosi 3iv  15  c.c. 

Tinct.  opii  camphorat 5iv  15  c.c. 

Liquor,   potassii   citratis 

q.  s.  ad  §vj  ad  180  c.c. 

M.  S. — Dessertspoonful  every  three  hours. 

Early  in  an  attack,  with  high  temperature  in  children,  tincture  of 
aconite,  in  small,  frequently  repeated  doses  is  valuable.  If  the  fever 
persists,  a  combination  of  phenacetin  or  antifebrin  with  camphor  or 
digitalis  is  useful.  The  ice-bags  or  poultices  are  as  strongly  recom- 
mended for  bronchopneumonia  as  for  lobar  pneumonia,  and  in  sthenic 
cases  should  be  given  a  yial. 


5i6  "fibroid  pneumonia 

For  the  catarrhal  process,  the  air  of  the  apartment  should  be  main- 
tained at  an  even  temperature  and  moistened  by  disengaging  the 
vapor  of  water  in  it.  The  following  combination  is  of  great  utility 
in  nearly  all  cases,  regulating  the  dose  in  accordance  with  the  age  of 
the  patient. 

I^.     Ammonii  carbonat gr.  v  0.3  gm. 

Potassii  iodidi gr.  v  0.3  gm. 

Mucil.  acaciae q.  s.  q.  s. 

Mist,  glycyrrh.  comp 5j  4-0  c.c. 

Syr.  prun.  virg q.  s.  ad   5iv  ad  15.0  c.c. 

M.  S. — Every  three  hours. 

A  more  pleasant  way  of  administering  the  ammonium  salts  is  in 
capsules,  each  containing  about  2)-^  gr.  of  each  salt  with  an  aromatic 
oil.  Terpin  hydrate  acts  remarkably  well  in  many  lingering  cases. 
The  aromatic  spirit  of  ammonia  in  either  chloroform  water  or  cherry- 
laurel  water  makes  an  excellent  mild,  stimulating  expectorant. 

During  convalescence,  tonics  such  as  iron,  cod-liver  oil,  syrup  of 
the  iodide  of  iron,  etc.,  and  good  food  are  indicated. 

FIBROID  PNEUMONIA 

Synonyms. — Chronic  interstitial  pneumonia;  cirrhosis  of  the  lung. 

Fibroid  pneumonia  is  a  chronic  disease  of  the  lungs,  characterized 
by  a  marked  overgrowth  of  connective  tissue,  or  cirrhosis ;  this  over- 
growth contracts  later  on  and  causes  a  diminution  of  air  space.  It 
may,  in  rare  instances,  follow  croupous  or  catarrhal  pneumonia  and 
chronic  pleurisy.  Inhalation  of  irritant  particles  of  dust,  stone,  coal, 
etc.,  over  a  long  period,  are  common  causes.  It  is  in  most  cases  due 
to  tuberculosis,  but  also  arises  independently  of  that  affection.  The 
signs,  symptoms,  and  morbid  anatomy  of  fibroid  pneumonia  and 
fibroid  phthisis  are  the  same,  with  the  exception  that  the  tubercle 
bacillus  may  be  demonstrated  in  the  sputum  of  the  latter  (see  Fibroid 
Phthisis). 

DISEASES  OF  THE  PLEURA 

PLEURISY 

Synonyms. — Pleuritis;  '^stitch  in  the  side." 

Definition. — A  fibrinous  inflammation  of  the  pleura,  either  acute, 
subacute,  or  chronic  in  character,  occurring  either  idiopathically  or 


PLEURISY  517 

secondarily;  characterized  by  a  sharp  pain  in  the  side,  a  dry  cough, 
dyspnea,  and  fever.  It  may  be  limited  to  a  part,  or  may  involve  the 
whole  of  one  or  both  pleural  membranes. 

Causes. — Idiopathic  pleurisy  is  said  to  be  due  to  cold  and  exposure, 
to  injuries  of  the  chest  walls,  or  muscular  exertion.  Tuberculosis  is 
the  cause  in  a  few  instances. 

Secondary  pleurisy  occurs  during  an  attack  of  pneumonia,  peri- 
carditis, rheumatism,  variola,  scarlatina,  measles,  Bright's  disease, 
tuberculosis,  or  puerperal  fever. 

Chronic  pleurisy  follows  an  acute  attack,  or  is  the  result  of  tuber- 
culosis, Bright's  disease,  cancer,  or  alcoholism. 

Pathology. — As  in  inflammation  of  other  serous  membranes  there 
are  five  stages — hyperemia,  exudation,  effusion,  absorption,  and 
adhesions. 

The  first  stage  is  marked  by  congestion  and  irregularly  diffused 
redness  of  the  membrane  with  scattered  flakes  of  exudation.  The 
second  stage  is  characterized  by  the  copious  formation  of  lymph, 
which  more  or  less  completely  covers  the  membrane,  giving  it  a  dull, 
cloudy,  or  shaggy  appearance.  If  the  inflammation  ceases  at  this 
period,  it  is  termed  dry  pleurisy.  If  the  condition  progresses  an 
effusion  is  poured  out  into  the  pleural  cavity,  which  may  be  serofib- 
rinous, or  purulent.  The  serofibrinous  variety  is  most  frequent  and 
consists  of  a  straw-colored  fluid  containing  fibrinous  fiocculi,  blood, 
and  epithelial  cells.  Its  quantity  is  usually  rather  large.  When  the 
exudate  is  fibrinous,  the  amount  is  small  and  the  consistency  is  greater 
than  that  of  the  preceding.  It  undergoes  organization  quickly  and 
gives  rise  to  adhesions  and  pleural  thickening.  The  exudate  be- 
comes purulent  (empyema)  only  as  the  result  of  microorganismal 
infection.  The  effusion  may  become  bloody  in  some  instances  as  the 
result  of  ulceration  (tuberculous  or  cancerous)  and  grave  blood  dis- 
eases. Displacement  of  the  viscera  is  common  in  this  stage;  if  on  the 
right  side,  the  effusion  pushes  the  heart  farther  to  the  left;  if  on  the 
left  side,  the  heart  is  displaced  to  the  right,  the  impulse  often  being 
seen  to  the  right  of  the  sternum.  The  lungs  are  also  compressed  and 
displaced  upward  and  against  the  spinal  column.  On  removal  of  the 
fluid  they  again  expand,  except  in  cases  of  chronic  pleurisy,  in  which 
the  adhesions  interfere  with  the  functional  activity  of  the  pulmonary 
structure.  Absorption  of  the  effused  material  is  the  natural  sequence 
in  most  cases.  Unabsorbed  portions  undergo  organization,  producing 
adhesions,  which,  in  extreme  instances  may  obliterate  the  entire 


5l8  PLEURISY 

pleural  cavity.  Sacculation  of  the  effusion  by  adhesions  is  not  un- 
common, especially  in  purulent  exudations  in  which  the  adhesions 
form  an  abscess  wall.  Varying  degrees  of  adhesion  of  the  opposing 
pleural  surfaces  are  encountered,  depending  on  the  character  of  the 
exudate. 

Chronic  pleurisy  results  when  the  fluid  is  not  absorbed  or  when  it  is 
effused  into  the  cavity  very  slowly.  The  membrane  is  irregularly 
thickened  and  firm  adhesions  are  formed  within  the  meshes  of  which 
the  fluid  is  found.  .Retraction  of  the  thoracic  wall  may  be  observed. 
If  the  fluid  is  pus,  it  may  rarely  become  inspissated  and  encapsulated, 
or  it  may  rupture  through  the  chest  wall,  discharging  externally 
through  a  fistula,  or  it  may  rupture  into  the  bronchi  or  in  very  rare 
instances  into  the  intestines. 

Symptoms. — The  acute  variety  begins  with  a  chill,  followed  by  a 
sharp  lancinating  pain  (stitch)  near  the  nipple  or  in  the  axilla,  aggra- 
vated by  coughing  and  breathing,  and  associated  with  slight  tender- 
ness on  pressure.  The  respirations  are  rapid  and  shallow,  30  to  35 
per  minute,  and  there  are  present  a  short,  dry,  hacking  cough,  moder- 
ate fever,  and  compressible  pulse  (90  to  120).  With  the  effusion  of 
liquid,  the  pain  diminishes;  dyspnea  becomes  more  aggravated;  cyano- 
sis develops;  the  cough  becomes  distressing;  and  the  cardiac  action 
greatly  embarrassed,  the  countenance  wearing  an  anxious  expression. 
The  patient  usually  lies  on  the  affected  side.  With  the  absorption  of 
the  fluid  the  symptoms  gradually  ameliorate,  convalescence  being 
rather  rapid  in  simple  cases. 

The  subacute  variety  begins  insidiously  after  cold,  exposure,  and 
fatigue,  in  individuals  enfeebled  from  various  causes.  The  patients 
usually  complain  of  a  sense  of  weariness,  shortness  of  breath,  aggra- 
vated on  exertion,  evening  fever,  followed  by  night-sweats,  and  a  short 
harassing  cough,  with  little  or  no  expectoration.  The  pulse  is  small, ' 
feeble,  but  frequent,  100  to  120  beats  per  minute.  The  characteristic 
pain  in  the  side  of  acute  pleurisy  is  absent. 

The  chronic  variety  is  characterized  by  a  more  prolonged  course, 
irregular  chills,  fever,  night -sweats,  dyspnea,  palpitation,  embar- 
rassed circulation,  and  more  or  less  prostration. 

Physical  Signs. — Inspection  during  the  early  stage  serves  to  detect 
deficient  movement  of  the  affected  side  on  account  of  the  pain  induced 
by  full  breathing.  After  the  effusion  has  formed  there  will  be 
observed  bulging  or  fullness  of  the  affected  side,  with  obliteration  of 
the  intercostal  spaces  and  displacement  of  the  cardiac  impulse. 


PLEURISY  519 

Palpation  demonstrates  feeble,  or  absence  of,  vocal  fremitus  over 
the  effusion,  with  exaggeration  of  the  same  above  the  fluid.  The 
affected  side  is  immobile,  and  very  rarely  fluctuation  may  be  obtained. 

Percussion  during  the  early  stage  yields  a  slightly  impaired  note. 
Later,  dullness  or  even  flatness,  with  increased  resistance  may  be  ob- 
tained directly  over  the  fluid,  while  above  the  effusion  the  percussion- 
note  is  tympanitic.  The  line  of  demarcation  is  higher  behind  than 
in  front.  Effusion  of  the  left  pleural  cavity  obliterates  Traube's 
semilunar  space.  The  fluid  changes  its  level  with  different  positions 
of  the  body  and  the  area  of  dullness  is  correspondingly  movable. 

Auscultation  reveals  4^ring  the  early  stage  a  feeble  vesicular  mur- 
mur over  the  affected  side,  the  patient  breathing  lightly  to  prevent 
pain.  A  friction  sound,  slight  and  grating  or  creaking,  becoming 
louder  as  the  exudation  of  lymph  increases,  limited  usually  to  the 
angle  of  the  scapula  of  the  affected  side,  rarely  over  the  entire  side, 
accompanies  the  respiratory  movements.  During  the  stage  of  effu- 
sion, the  vesicular  murmur  is  feeble  or  absent  on  the  affected  side 
depending  upon  partial  or  complete  compression  of  the  lung  by  fluid. 
Above  the  effusion,  puerile  breathing  is  heard,  and  just  at  the  upper 
margin  of  the  fluid  a  friction  sound  may  be  heard.  Vocal  resonance 
is  diminished  or  absent  over  the  fluid  and  markedly  increased  above 
the  effusion,  egophony  being  obtained  at  its  upper  margin.  With 
the  absorption  of  the  fluid,  the  vesicular  murmur  and  the  moist 
friction  sound  gradually  return. 

Diagnosis. — Acute  pneumonia  may  be  distinguished  from  pleurisy 
by  the  pronounced  chill,  high  fever,  rusty  sputum,  increased  tactile 
fremitus,  bronchial  breathing,  fine,  crackling,  inspiratory  rales,  in- 
creased vocal  resonance,  fixed  dullness,  absence  of  intercostal  bulging, 
and  the  absence  of  cardiac  displacement. 

Rheumatism  of  the  intercostal  muscles,  or  pleurodynia,  is  character- 
ized by  more  diffuse  pain  and  tenderness.  The  physical  signs  are 
negative. 

Enlargement  of  the  liver  may  be  mistaken  for  pleurisy  with  effusion, 
the  chief  point  of  distinction  being  that,  in  enlargement  of  the  liver, 
the  superior  line  of  dullness  is  depressed  upon  full  inspiration,  while 
in  pleurisy,  with  effusion,  inspiration  does  not  modify  the  location  of 
the  dullness. 

Pericarditis  with  efusioji  is  attended  by  physical  signs  limited  to 
the  precordium' and  symptoms  referable  to  embarrassed  circulation. 

Empyema  is  attended  by  septic  phepomepa  in  addition  to. physical 


520  PLEURISY 

signs  indicating  pleural  effusion.  High  and  irregular  fever,  chills, 
sweats,  and  leukocytosis  are  present.  Aspiration  yields  pus  and  pus- 
producing  microorganisms.  Also  the  whispered  voice  is  inaudible 
over  pus,  while  it  can  be  heard  over  serous  fluid  [BaccelWs  sign). 

Hydrothorax  may  be  distinguished  by  its  previous  history,  the 
absence  of  pain  and  fever,  and  on  aspiration  the  withdrawal  of  an 
albuminous  fluid  of  low  specific  gravity. 

Prognosis. — Idiopathic  pleurisy  usually  terminates  in  recovery 
within  three  weeks.  Pleurisy,  the  result  of  constitutional  causes,  has 
its  progress  modified  by  the  condition  with  which  it  is  associated. 
Empyema,  unless  the  result  of  a  diathesis,  terminates  favorably  with 
prompt  treatment.  Double  pleurisy  is  unfavorable.  The  etiological 
factor  of  tuberculosis  may  always  be  borne  in  mind  in  making  a  prog- 
nosis in  pleurisy,  whether  acute  or  chronic.  When  the  effusion  is  very 
large  the  possibility  of  sudden  death  should  always  be  considered. 

Treatment. — The  patient  should  be  immediately  placed  at  rest  in 
bed  and  the  diet  restricted  to  liquids  or  semisolid  substances.  The 
administration  of  fractional  doses  of  calomel,  followed  by  a  saline, 
should  begin  the  medication.  At  the  onset,  in  robust  individuals, 
wet  cups  should  be  applied  to  the  affected  side  to  relieve  the  pain;  if 
the  pain  is  very  severe,  the  dyspnea  great,  and  the  arterial  tension 
high,  venesection  may  be  employed.  In  anemic  and  weak  individuals 
dry  cups  should  be  used.  Either  wet  or  dry  cups  should  be  followed 
by  the  application  of  poultices  or  turpentine  stupes.  Severe  pain  is 
promptly  relieved  by  the  hypodermic  injection  of  morphine  sulphate, 
gr.  ]/Q  (o.oi  gm.),  repeated  as  necessary,  or  by  the  internal  administra- 
tion of  small  doses  of  Dover's  powder.  Strapping  the  affected  side 
by  means  of  broad  strips  of  adhesive  plaster  is  of  benefit  in  all  cases. 
In  the  very  early  stages,  the  disease  may  be  cut  short  to  some  extent 
by  the  administration  of  sodium  salicylate,  gr.  xv  to  xx  (i  to  1.3  gm.), 
well  diluted,  every  three  or  four  hours.  The  salicylates  are  also  use- 
ful during  the  stage  of  effusion.  After  effusion  has  begun,  fluidex- 
tract  of  pilocarpine,  lUxv  (i  c.c),  every  two  or  three  hours,  or  in  dram 
doses  every  other  day  for  a  week  or  two,  and  later  twice  weekly,  or  the 
following  should  be  administered: 

I^.     Potassii  acetat gr.  xxx  2  gm. 

Infus.  digitalis 5ij  8  c.c. 

M.  S. — Every  three  or  four  hours. 

Matthew  Hay,  of  Scotland,  employs  a  concentrated  solution  of 


HYDROTHORAX  52 1 

magnesium  sulphate  for  the  removal  of  the  effusion.  He  advises 
that  the  patient  should  take  nothing  after  the  evening  meal,  and 
then  an  hour  or  so  before  breakfast,  the  salt  (from  3iv  to  vj  (15  to 
24  gm.)  to  5j  to  ij  (30  to  60  gm.)  dissolved  in  an  ounce  or  two  of 
water)  is  given,  no  fluids  to  be  used  after  its  administration.  This 
usually  produces  from  four  to  eight  watery  stools,  without  pain  or 
discomfort,  and  also  acts  as  a  diuretic.  Other  diuretics,  such  as 
digitalis,  caffeine,  potassium  acetate,  and  Basham's  mixture,  may  also 
be  employed.  Diaphoretics  have  little  or  no  effect  on  the  effusion. 
Bowditch  advocates  early  aspiration.  If  after  three  or  four  days  no 
impression  is  made  upon  the  effusion  by  other  means,  aspiration 
should  be  employed,  and  followed  by  tablespoonful  doses  of  Basham's 
mixture  every  four  hours,  and  an  early  morning  dose  of  magnesium 
sulphate,  5ss  to  j  (15  to  30  gm.),  well  diluted.  Perhaps  a  better 
plan  would  be,  to  be  guided  by  the  duration  and  character  of  the 
effusion  (if  it  is  profuse,  or  increases  rapidly  in  amount)  the  degree 
of  dyspnea  and  disturbance  of  the  heart,  and  the  visceral  displace- 
ment. The  puncture  is  usually  made  in  the  sixth  or  seventh  inter- 
costal space  between  the  scapula  and  the  axilla.  If  these  means 
do  not  influence  the  effusion,  potassium  iodide,  gr.  xv  (i  gm.),  diluted, 
should  be  administered  every  four  hours,  and  flying  blisters  should 
be  applied  over  the  affected  side,  or  blue  ointment  (mercurial  oint- 
ment) should  be  rubbed  into  the  armpits,  groins,  and  over  the  effusion. 
Painting  of  the  affected  side  with  iodine  may  also  be  employed. 

In  chronic  pleurisy,  blisters  and  iodine  should  be  used  locally, 
and  potassium  iodide  alternating  with  Basham's  mixture,  should  be 
administered  internally. 

In  purulent  pleural  effusion  {empyema),  aspiration  is  of  little 
value  except  for  diagnostic  purposes  as  the  pus  reaccumulates. 
Incision  of  the  chest  between  the  fifth  and  sixth  ribs  with  the  in- 
sertion of  a  drainage-tube  is  then  indicated;  the  pleural  sac  should 
be  treated  then  as  an  abscess  cavity.  More  drastic  surgical  meas- 
ures are  often  necessary,  such  as  excision  of  one  or  more  ribs. 
Basham's  mixture,  stimulants,  and  quinine  should  be  given  internally 
in  addition. 

HYDROTHORAX 

S5monym. — Dropsy  of  the  pleura. 

Definition. — The  effusion  of  fluid  into  the  pleural  cavities  (bilateral) , 
the  result  of  a  general  dropsy  from  renal  or  cardiac  disease.     The 


522  PNEUMOTHORAX 

effusion  consists  of  a  more  or  less  clear  serous  fluid  which  occupies 
both  pleural  sacs.     There  are  no  signs  of  inflammation. 

Sjnnptoms. — It  is  accompanied  by  dyspnea,  cyanosis,  due  to 
deficient  blood  aeration  from  compression  of  the  lungs,  and  symptoms 
referable  to  the  primary  disease.  The  physical  signs  are  those  of 
pleural  effusion. 

Diagnosis. — The  history,  bilateral  character,  and  the  absence 
of  pain  and  fever  serve  to  distinguish  it  from  other  pleural  conditions. 

Prognosis. — This  is  controlled  almost  entirely  by  the  primary 
cause  producing  the  general  dropsy. 

Treatment. — The  pleural  condition  will  necessitate  the  adminis- 
tration of  hydragogue  cathartics  and  diuretics;  and  at  times  aspira- 
tion will  be  required.     Dry  cups  over  the  chest  may  afford  some  relief. 

PNEUMOTHORAX 

S3m.onyms. — Air  in  the  pleural  cavity;  hydropneumothorax. 

Definition. — The  accumulation  of  air  or  gas  in  the  pleural  cavities, 
with  the  consequent  development  of  inflammation  of  the  membranes ; 
characterized  by  sharp  pain,  followed  by  rapidly  developing  dyspnea 
and  cough. 

Causes. — It  generally  results  from  tuberculous  ulcers  perforating 
the  pleura.  Abscess,  gangrene,  and  emphysema  may  be  causes. 
Perforation  may  take  place  from  the  pleura  into  the  lung  as  the  result 
of  empyema  or  abscess  of  the  chest  wall.  Direct  perforation  from 
without  may  follow  fractures  of  the  ribs,  penetrating  wounds,  and 
severe  contusions. 

Pathological  Anatomy. — The  gas  in  the  pleural  cavity  consists 
of  oxygen,  carbon  dioxide,  and  nitrogen  in  variable  proportions. 
It  may  fill  the  pleural  sac  completely,  compressing  the  lung,  or  may 
be  limited  by  adhesions.  The  gas  tends  to  excite  inflammation,  the 
resulting  effusion  being  either  serous  or  purulent. 

Symptoms. — The  onset  is  abrupt  with  sudden  or  sharp  pain  in 
the  side,  intense  dyspnea,  symptoms  of  collapse,  coldness  of  the 
surface,  and  cold  sweats.  These  symptoms  in  many  instances  follow 
a  severe  or  violent  paroxysm  of  coughing.  In  severe  cases  the  acute 
pain  and  distressing  dyspnea  are  constant  until  death. 

Physical  Signs. — Inspection  serves  to  detect  enlargement  of  the 
affected  side,  with  absent  or  diminished  respiratory  movements. 
The  intercostal  spaces  are  widened  and  sometimes  bulged  out  so  that 
the  surface  of  the  chest  is  smooth.     The  apex  beat  is  displaced. 


GENERAL    SYMPTOMATOLOGY  523 

Palpation  reveals  diminished  tactile  fremitus. 

Percussion  yields  marked  changes  in  the  resonance.  Immediately 
after  the  rupture,  the  percussion-note  is  hyper-resonant,  or  even 
tympanitic  or  amphoric  in  quality.  If  the  amount  of  air  in  the  pleural 
cavity  becomes  extreme,  there  is  dullness  on  percussion,  associated 
with  a  feeling  of  great  resistance  or  density.  When  effusion  of  blood 
occurs,  dullness  is  obtained  over  the  lower  part  of  the  chest,  hyper- 
resonant,  or  tympanitic  percussion-note  over  the  upper  portions  of 
the  chest,  these  sounds  changing  as  the  patient  changes  position. 

Auscultation  demonstrates  several  characteristic  features.  The 
normal  vesicular  murmur  may  be  diminished  or  absent.  The 
typical  amphoric  respiratory  sound  is  heard  when  the  fistula  is  open, 
usually  associated  with  a  metallic  echo.  The  vocal  resonance  may 
be  diminished  or  absent,  or,  rarely,  it  may  be  exaggerated,  with  a 
distinct  metallic  echo. 

Metallic  tinkling,  or  the  bell  sound,  is  sometimes  distinctly  pro- 
duced by  breathing,  coughing,  or  speaking,  after  the  development  of 
inflammation  of  the  pleura. 

After  the  development  of  pleuritis,  suddenly  shaking  the  patient 
gives  rise  to  a  splashing  sensation,  the  succussion  sound,  if  both  air 
and  fluid  are  present  in  the  pleural  cavity. 

Diagnosis. — The  distinctive  features  of  this  affection  are  the 
history,  situation,  symptoms,  and  physical  signs,  the  careful  con- 
sideration of  which  will  prevent  errors  in  diagnosis. 

Prognosis. — When  occurring  as  the  result  of  tuberculosis,  the 
prognosis  is  extremely  unfavorable;  rarely,  the  fistulous  opening  is 
closed  by  inflammatory  action;  the  case  then  becomes  one  of  chronic 
pleurisy.  Cases  due  to  other  causes  are  less  grave  but  are  neverthe- 
less serious. 

Treatment. — Morphine  should  be  administered  hypodermically 
at  once,  and  diffusible  stimulants,  ammonia,  alcohol,  ether,  etc., 
given  at  once.  Aspiration  of  the  chest  followed  by  strapping  may 
afford  relief  at  times.  Apart  from  these  simple  procedures  the 
treatment  is  that  of  the  primary  disease. 

DISEASES  OF  THE  NERVOUS  SYSTEM 

GENERAL  SYMPTOMATOLOGY 

Motor  Phenomena. — The  motor  disturbances  incident  to  nervous 
diseases  may  be  manifested  as  paralysis  or  loss  of  motion,  or  as 


524  GENERAL    SYMPTOMATOLOGY 

excessive  motor  discharges  including  convulsions,  tremors,  and 
choreiform  movements. 

Paralysis  involving  a  lateral  half  of  the  body  is  termed  hemi- 
plegia; when  involving  the  body  from  the  waist  down,  paraplegia; 
when  involving  a  single  member,  monoplegia;  and  when  involving 
similar  parts  on  both  sides  of  the  body,  diplegia. 

Paralysis  may  be  irregularly  distributed  and  in  such  cases  may 
be  due  to  localized  disease  of  the  muscles  or  nerves  of  the  affected 
region,  or  to  syringomyelia,  disseminated  lesions  in  the  motor  area 
of  the  brain,  lesions  of  the  basal  ganglia,  and  poliomyelitis  (acute 
and  chronic). 

Hemiplegia  usually  results  from  hemorrhage  at  the  base  of  the 
brain  injuring  the  internal  capsule,  corpus  striatum,  or  optic  thalamus. 
The  paralysis  occurs  on  the  opposite  side  of  the  body.  As  other 
causes  of  unilateral  paralysis  may  be  mentioned  lesions  of  the  motor 
cortex,  crus  cerebri,  or  pons,  a  unilateral  lesion  high  up  in  the  spinal 
cord,  and  hysteria. 

Paraplegia  may  be  due  to  multiple  neuritis,  caisson  disease,  or 
hysteria,  but  in  most  cases  is  the  result  of  injury  or  disease  of  the 
spinal  cord  such  as  occurs  in  fracture  or  caries  of  the  verterbrae, 
morbid  gro"v\i:hs,  aneurysm,  hemorrhage,  acute  myelitis,  chronic 
myelitis,  Landry's  disease,  and  lateral  sclerosis.  Injury  to  the 
brain  during  delivery  may  induce  spastic  paraplegia. 

Monoplegia  may  result  from  disease  or  injury  of  a  peripheral  nerve, 
a  focal  lesion  in  the  cortex,  or  from  hysteria. 

Diplegia,  is,  of  course,  a  double  hemiplegia. 

Convulsions  may  be  defined  as  general  involuntary  paroxysms  of 
muscular  contraction.  They  may  consist  of  continuous  contractions, 
tonic;  or  intermittent  contractions,  clonic.  They  may  be  general  or 
local.  They  are  usually  considered  as  of  three  varieties,  epileptiform, 
tetanic,  and  hysteroidal.  When  only  a  single  muscle  or  group  of 
muscles  is  involved,  the  condition  is  called  a  spasm. 

Epileptiform  convulsions  may  be  observed  in  epilepsy,  organic 
brain  disease,  cerebral  anemia,  uremia,  and  other  toxemias  such 
as  eclampsia,  infectious  fevers,  etc.,  and  reflex  conditions,  especially 
those  referable  to  the  digestive  tract.  Unconsciousness  is  usually 
present  and  the  contractions  are  mostly  clonic. 

Tetanic  convulsions  occur  in  tetanus,  tetany,  spinal  meningitis, 
and  strychnine  poisoning.     Consciousness  is  retained. 

Hysteroidal    convulsions   follow   no   fixed   rule.     Consciousness  is 


GENERAL    SYMPTOMATOLOGY  525 

never  entirely  lost.  Other  hysterical  manifestations  are  present  and 
the  patient  never  inflicts  injury  upon  herself. 

Tremors  are  involuntary  vibratory  movements  and  are  produced 
by  alternate  contraction  and  relaxation  of  antagonistic  muscles. 
They  are  observed  most  often  in  the  arms,  head,  face,  tongue,  and 
hands.  They  may  be  coarse  or  fine.  Tremors  occur  in  chronic 
alcoholism,  delirium  tremens,  paralysis  agitans,  and  in  poisoning  by 
lead,  mercury,  arsenic,  chloral,  and  opium.  Neurasthenia,  debility 
from  various  causes,  senility,  hysteria,  disseminated  sclerosis, 
exophthalmic  goitre,  and  paresis  are  accompanied  by  tremors.  In 
disseminated  sclerosis,  the  tremor  is  irregular,  jerky,  and  increased 
by  voluntary  efforts  to  restrain  it.  The  tremor  is  absent  during 
rest  but  is  brought  about  by  movement.  In  paralysis  agitans,  it 
is  regular  and  rhythmic,  occurring  both  during  rest  and  movement. 
The  tremor  of  senility  is  exceedingly  fine  and  begins  in  the  hands, 
often  extending  to  the  face.  It  occurs  at  first  only  during  motion, 
disappearing  during  rest.  When  age  is  far  advanced  it  may  occur 
during  both  rest  and  movement. 

Choreiform  movements  are  coarse,  incoordinated,  involuntary 
movements  of  a  jerky  and  irregular  character  usually  separated  by 
short  intervals.  They  may  simulate,  to  some  extent,  purposeful 
movements.  Among  the  causes  may  be  mentioned  idiopathic  chorea, 
Huntingdon's  chorea,  post-hemiplegic  chorea,  organic  brain  disease, 
habit,  hysteria,  reflex  irritation,  etc. 

Athetoid  movements  are  slow,  more  or  less  rhythmic  twisting 
movements  of  the  fingers  and  toes.  They  are  observed  in  cerebral 
palsies  of  children,  after  hemiplegia  in  adults,  and  poliencephalitis. 

The  gait  may  also  be  taken  as  an  index  of  the  character  of  the 
nervous  condition  present.  The  ataxic  gait  is  especially  characteristic 
of  locomotor  ataxia.  In  it,  the  patient  raises  the  foot  very  high, 
throws  it  outward  and  forward,  and  allows  it  to  fall  suddenly  to 
the  ground  in  an  awkward  manner.  The  spastic  gait  observed  in 
spastic  paraplegia  is  characterized  by  stiff  movements  of  the  lower 
extremities.  The  knees  are  somewhat  flexed  and  approach  each 
other,  and  the  toe  drags  on  the  ground  with  each  step.  The  festinat- 
ing  gait,  or  the  gait  of  paralysis  agitans  in  the  later  stages  is  dis- 
tinguished by  the  following  features :  As  the  patient  walks,  the  body 
bends  forward  and  the  steps  follow  each  other  in  rapid  succession 
until  the  patient  falls  or  supports  himself  by  means  of  some  nearby 
object.     After  a  very  short  interval  in  which  equilibrium  is  obtained, 


526  GENERAL   SYMPTOMATOLOGY 

the  patient  repeats  the  cycle.  The  steppage  gait  is  that  in  which  the 
foot  is  highly  elevated  and  the  toe  turned  up  in  taking  a  step.  In 
bringing  the  foot  down  the  heel  is  first  placed  on  the  ground.  This 
gait  occurs  in  multiple  neuritis.  Tituhation  is  the  term  applied  to 
that  gait  in  which  there  is  considerable  swaggering  and  swaying, 
particularly  that  form  occurring  in  disease  of  the  cerebellum. 

The  reflexes  are  motor  phenomena  to  which  the  attention  should 
always  be  directed  in  considering  diseases  of  the  nervous  system. 
They  are  of  two  kinds:  cutaneous  reflexes  and  tendon  reflexes. 

The  cutaneous  reflexes  are  superficial  reflexes  and  consist  of  muscu- 
lar contractions  produced  by  irritation  of  the  sensory  nerves  in  the 
skin.  The  contractions  induced  by  tickling  the  soles  of  the  feet  may 
be  mentioned  as  examples.  Various  names  are  applied  to  these  re- 
flexes according  to  the  situations  in  which  they  occur.  Cutaneous 
reflexes  may  be  delayed  in  certain  nervous  diseases,  and  in  others  the 
response  to  irritation  may  be  prompt  and  extend  over  the  entire  body . 
They  are  absent  in  shock,  diseases  of  the  brain  and  spinal  cord  involv- 
ing the  reflex  centers,  and  diseases  of  the  peripheral  nerves.  They 
are  increased  in  affections  in  which  there  is  increased  irritability  of 
the  cutaneous  nerves,  as  in  tetanus,  strychnine  poisoning,  general 
neuroses,  etc. 

The  tendon  reflexes  are  the  muscle  contractions  produced  by  gently 
tapping  the  tendons  while  the  corresponding  muscles  are  placed 
slightly  upon  the  stretch.  The  same  effect,  but  of  less  intensity, 
may  be  produced  by  striking  the  adjacent  fascia  and  periosteum. 

The  knee-jerk  or  patellar  reflex  is  produced  by  striking  the  tendon  of 
the  quadriceps  extensor  muscle  between  the  patella  and  its  insertion 
while  the  patient  crosses  the  leg  loosely  over  the  opposite  knee  or 
allows  it  to  hang,  relaxed,  over  the  forearm  of  the  examiner.  Simul- 
taneous muscular  effort  on  the  part  of  the  patient  will  serve  to  in- 
crease the  reflex.  The  knee-jerk  is  increased  in  lateral  sclerosis,  dis- 
seminated sclerosis,  incomplete  lesions  of  the  cord  above  the  lumbar 
segment,  irritability  of  the  spinal  cord  such  as  occurs  in  spinal  men- 
ingitis, strychnine  poisoning,  hysteria,  etc.,  and  in  some  cases  of 
organic  cerebral  disease.  It  is  diminished  or  absent  in  locomotor 
ataxia,  neuritis,  pseudo-muscular  hypertrophy,  poliornyelitis,  myeli- 
tis, and  in  poisoning  by  spinal  depressant  drugs.  Pronounced  phys- 
ical exhaustion  also  serves  to  lessen  the  tendon  reflexes. 

Ankle-clonus  is  the  term  applied  to  the  vibratory  movements  of  the 
foot  produced  by  forcible  dorsal  flexion  of  the  foot.     It  is  seldom  if 


GENERAL    SYMPTOMATOLOGY  527 

ever  obtained  during  health,  being  observed  most  often  in  lateral 
sclerosis  and  hysteria. 

The  Bahinski  reflex  is  the  extension  of  the  great  toe  which  follows 
tickling  the  sole  of  the  foot.  Normally  flexion  follows  such  a  proce- 
dure. The  reflex  occurs  most  often  in  hemiplegia,  diplegia,  and  dis- 
eases of  the  motor  tract  of  the  cord. 

Other  reflexes  occur  in  connection  with  the  arm,  arm-jerk,  and  the 
jaw,  jaw-jerk,  and  are  obtained  by  striking  their  respective  muscles 
while  in  a  state  of  partial  extension.  The  contraction  of  the  pupil  on 
exposure  to  light,  the  closure  of  the  eyelids  on  irritation  of  the  cornea 
or  conjunctiva,  sneezing  following  irritation  of  the  nares,  and  other 
similar  reflexes  are  entitled  to  mention  in  this  connection. 

Paradoxical  contraction  consists  of  a  tetanic  contraction  of  the  tib- 
ialis anticus  produced  by  forcibly  flexing  the  foot  on  the  leg.  The 
foot  remains  flexed  for  several  minutes  after  which  it  slowly  relaxes. 
It  was  first  described  by  Westphal,  and  may  be  observed  in  tabes 
dorsalis,  hysteria,  paralysis  agitans,  and  multiple  sclerosis.  The 
phenomenon  may  occasionally  be  produced  in  the  flexors  of  the  leg 
and  forearm. 

Vasomotor  Disturbances. — Paralysis  of  the  vasomotor  system  oc- 
curs as  a  symptom  of  hysteria,  neurasthenia,  and  other  functional 
neuroses,  and  follows  injuries  of  the  sympathetic  nerve.  It  is  mani- 
fested by  abnormal  redness  of  the  skin  with  a  sensation  of  heat  and  a 
rise  in  the  dermal  temperature.  Vasomotor  spasm  is  indicated  by 
pallor  and  coolness  of  the  skin  with  formication  and  stiffness.  It  is 
observed  with  functional  disturbances  of  the  sympathetic  system  and 
may  be  followed  by  trophic  disturbances  such  as  occur  in  scleroderma 
and  symmetrical  gangrene. 

Sensory  Phenomena. — Sensibility  may  be  increased,  hyperesthesia; 
decreased  or  absent,  anesthesia;  or  perverted,  paresthesia. 

In  hyperesthesia,  the  increase  is  often  so  great  that  even  the  slight- 
est irritation  may  produce  pain.  It  may  be  due  to  inflammation  of 
the  nerves  as  in  sciatica  and  multiple  neuritis  when  it  is  associated 
with  tenderness  on  pressure.  It  is  also  present  in  inflammation  of 
the  meninges,  neurasthenia,  and  hysteria. 

Anesthesia  oj  the  skin  may  be  complete  or  partial,  and  results  from 
any  disturbance  in  the  conducting  path  from  the  body  surface  to  the 
centers  of  sensation.  As  causes,  may  be  mentioned  neuritis,  trau- 
matism of  the  nerve  trunks,  organic  disease  of  the  sensory  tract  in  the 
spinal  cord  or  brain,  hysteria,  reflex  irritation,  drugs  such  as  morphine, 


528  GENERAL   SYMPTOMATOLOGY 

cocaine,  and  other  local  anesthetics,  and  caustics  such  as  the  mineral 
acids,  alkalies,  carbolic  acid,  etc. 

Hemianesthesia  is  the  term  applied  to  loss  of  sensation  on  a  lateral 
half  of  the  body.  It  is  usually  associated  with  hemiplegia  on  the  same 
side  except  when  due  to  a  unilateral  lesion  of  the  cord  in  its  upper 
segment,  when  the  hemiplegia  is  on  the  opposite  side.  The  condition 
is  due  in  most  cases  to  hemorrhages,  tumors,  or  local  softening  of 
the  posterior  limb  of  the  internal  capsule,  the  cms  or  peduncle,  the 
pons,  the  medulla,  or  the  occipital  cortex.  Hysteria  is  responsible 
for  a  number  of  cases  of  hemianesthesia.  These  cases  are  paroxys- 
mal in  character  and  unassociated  with  loss  of  motion. 

M onanesthesia  is  used  to  denote  loss  of  sensation  in  a  single  mem- 
ber. Inflammation,  injury,  or  other  lesion  of  the  corresponding 
sensory  nerve  is  the  most  common  cause,  but  it  may  also  arise  from 
focal  lesions  in  the  occipital  cortex,  and  hysteria. 

Paranesthesia  signifies  absence  of  sensibility  of  the  body  and  ex- 
tremities below  the  waist.  Organic  disease  of  the  spinal  cord  and 
neuritis  of  the  large  sensory  nerve  trunks  of  the  lower  extremities  are 
the  most  common  causes.  Hysteria  and  reflex  irritation  may,  how- 
ever, greatly  influence  its  production. 

Thermoanesthesia  is  a  variety  of  diminished  sensibility  of  the  skin 
in  which  it  is  impossible  to  appreciate  heat  or  cold  by  tactile  impres- 
sion. In  health,  it  is  possible  to  recognize  differences  of  2°F.  on  the 
back,  and  differences  of  3^^°  to  i°F.  on  the  fingers  and  face  at  tempera- 
tures from  80°  to  ioo°F.  In  disease,  the  temperature  sense  may  be 
lost  while  other  forms  of  irritation  are  appreciated.  It  may  be 
observed  in  syringomyelia  and  hysteria. 

Analgesia  is  that  condition  in  which  there  is  insensibility  to  pain 
as  produced  by  pinching  a  fold  of  skin,  pricking  with  a  needle,  or  by 
electric  currents.  Tactile  insensibility  does  not  necessarily  imply 
analgesia.  Loss  of  sensibility  to  pain  is  a  prominent  feature  of 
syringomyelia,  but  may  also  be  observed  in  peripheral  and  central 
nervous  disease  and  in  hysteria. 

Delayed  conduction  of  sensory  impulses  is  frequently  observed  in 
anesthesia  from  various  causes.  In  locomotor  ataxia,  it  is  particu- 
larly common. 

After-sensations  are  the  painful  sensations  which  succeed  momen- 
tary impressions  such  as  follow  the  prick  of  a  pin.  Sometimes  an 
isolated  prick  of  a  pin  is  not  appreciated,  requiring  repetition  of  the 
procedure  several  times,  after  which,  with  a  varying  interval,  the 


GENERAL   SYMPTOMATOLOGY  529 

painful  sensations  present  themselves.  This  phenomenon  is  espe- 
cially frequent  in  locomotor  ataxia  and  other  diseases  of  the  cord 
and  of  the  nerves. 

Muscular  sense,  or  sense  of  position,  is  the  sense  by  which  we 
are  conscious  of  the  position  of  our  limbs,  or  any  movement  of 
them. 

Paresthesia  is  a  term  applied  to  abnormal  sensations  in  the  skin  such 
as  numbness,  tingling,  itching,  pricking,  formications,  etc.  It  is 
observed  in  numerous  conditions  of  the  nervous  system  especially 
neurasthenia,  hysteria,  spinal  sclerosis,  and  disturbances  of  the  per- 
ipheral nerves.  The  girdle  sensations  which  occur  in  locomotor 
ataxia  and  other  forms  of  spinal  sclerosis  belong  to  this  class  of  sensory 
phenomena. 

Dysesthesia  is  that  condition  in  which  a  stimulus  is  wrongly  in- 
terpreted, e.g.,  a  prick  is  felt  as  a  sensation  of  numbness. 

Aster eo gnosis  is  the  inability  to  recognize  by  the  sense  of  touch  the 
shape  or  size  of  some  well-known  object. 

Neuralgia  is  the  term  applied  to  paroxysmal  pain  occurring  along 
the  line  of  the  nerve-trunks.  Pressure  usually  serves  to  relieve  it. 
Points  of  tenderness  may,  however,  be  elicited  where  the  affected 
nerve  emerges  from  a  bony  canal  or  from  beneath  muscular  coverings. 
The  lightning-pains  observed  in  locomotor  ataxia  are  sharp,  lancinat- 
ing, neuralgic  pains  occurring  usually  in  the  extremities.  Causalgia 
is  an  intense  burning  neuralgia  and  is  encountered  most  frequently 
in  the  condition  known  as  ' 'glossy  skin." 

Nutritive  Disturbances. — Atrophy  of  the  muscles  may  result  from 
acute  or  chronic  anterior  poliomyelitis,  inflammation  or  injury  of 
the  nerves,  idiopathic  muscular  disease,  or  disease  such  as  follows 
cerebral  palsies  and  joint  affections. 

Degeneration  of  the  muscles  may  be  determined  by  their  reaction 
to  the  galvanic  electric  current.  In  the  normal  muscle  the  kathodal 
closing  contraction  is  greater  than  the  anodal  closing  contraction,  and 
kathodal  opening  contraction  is  less  than  the  anodal  opening  con- 
traction. In  the  early  stages  of  degeneration  the  anodal  and  kathodal 
contractions  are  equal,  both  on  opening  and  on  closing  the  current. 
When  the  degeneration  is  advanced,  kathodal  closing  contraction  is 
less  than  anodal  closing  contraction,  and  kathodal  opening  contrac- 
tion is  greater  than  anodal  opening  contraction.  This,  it  will  be 
noticed,  is  a  reversal  of  the  reaction  of  normal  muscle.  These  degen- 
erative reactions  indicate  suspension  of  trojphic  influences  and  are 
34 


530  GENERAL    SYMPTOMATOLOGY 

symptomatic  of  acute  and  chronic  anterior  poliomyelitis,  acute 
central  myelitis,  and  inflammation,  traumatism,  or  other  disturbance 
of  the  nerves  which  arrests  their  functions. 

Arthropathies  may  occur  in  certain  organic  diseases  of  the  nervous 
system  such  as  syringomyelia  and  locomotor  ataxia,  and  consist 
of  swelling,  effusion,  and  degenerative  changes  in  the  joints. 

Ulceration  may  result  in  the  course  of  certain  diseases  of  the  nerv- 
ous system  from  coincident  disturbance  of  nutrition.  When  ulcera- 
tion occurs  on  parts  subjected  to  pressure,  within  a  few  days,  the 
term  acute  decubitus  may  be  employed  to  express  the  condition; 
when  ulcerative  lesions  appear  after  a  long  lapse  of  time  in  chronic 
nervous  diseases,  the  term  chronic  decubitus  is  applied.  Perforating 
ulcer  of  the  foot  such  as  occurs  in  locomotor  ataxia  may  also  be  men- 
tioned in  this  connection.  Somewhat  allied  to  ulceration  due  to 
nutritive  disturbances  is  spontaneous  gangrene  {Raynaud's  disease) 
which  involves  the  fingers,  toes,  ears,  nose,  etc.,  in  the  absence  of 
any  local  causes. 

Trophic  disturbances  involving  the  skin  and  its  appendages  include 
scleroderma,  chloasma,  vitiligo,  atrophia  unguis,  plica,  trichorrhexis 
nodosa,  etc. 

Alterations  in  Breathing. — Cheyne-Stokes  respiration  is  a  condition 
in  which  the  respirations  gradually  increase  in  volume  and  rapidity 
until  they  reach  a  climax,  when  they  gradually  subside,  and  finally 
cease  for  from  ten  to  forty  seconds,  when  the  same  cycle  begins  again. 
It  may  occur  in  tuberculous  meningitis,  cerebral  hemorrhage,  embol- 
ism, thrombosis,  aneurysm  of  basilar  artery,  uremia,  heart  disease, 
etc.     It  usually  indicates  a  fatal  issue. 

Disturbances  of  Consciousness. — The  principal  alterations  to 
which  consciousness  is  subject  in  nervous  diseases  are  coma,  trance, 
somnambulism,  ecstasy,  and  catalepsy. 

Coma  is  an  abnormally  deep  and  prolonged  sleep  in  which  the 
cerebral  functions  are  in  abeyance;  it  is  characterized  by  stertorous 
breathing,  relaxation  of  the  sphincters,  lividity  of  the  face,  loss  of 
parallelism  of  the  optic  axes,  and  an  inability  to  respond  to  external 
stimuli.  It  may  be  gradual  or  sudden  in  its  onset ;  complete  or  par- 
tial, transient  or  permanent.  It  may  be  due  to  organic  brain  disease, 
traumatism,  cerebral  anemia,  epilepsy,  sunstroke,  hysteria,  various 
convulsive  states,  and  various  toxic  agents  in  the  blood,  introduced 
either  from  without  or  produced  within  the  body. 

Trance  is  an  hysterical  manifestation  characterized  by  a  prolonged 


GENERAL    SYMPTOMATOLOGY  53 1 

abnormal  sleep  from  which  the  patient  cannot  be  aroused  and  in 
which  the  vital  functions  are  reduced  to  a  minimum. 

Somnambulism  is  a  condition  of  half-sleep  in  which  the  senses  are 
but  partially  suspended  and  the  patient  is  able  to  perform  various 
feats  automatically.  Ordinary  sleep-walking  may  occur  in  health 
but  the  more  pronounced  varieties  of  this  condition  ''are  observed 
in  hysteria  and  in  hypnotized  subjects. 

Ecstasy  is  a  peculiar  state  of  the  mind  in  which  a  delusion  so  governs 
the  mental  functions  that  the  entire  nervous  system  is  held  in  a  con- 
dition of  subjection  or  apparent  insensibility.  It  is  usually  a  mani- 
festation of  hysteria. 

Catalepsy  is  characterized  by  loss  of  will  and  by  muscular  rigidity. 
It  occurs  in  paroxysms  with  loss  of  consciousness,  the  limbs  remaining 
for  long  periods  in  any  position  in  which  they  are  placed.  It  occurs 
in  hysteria,  various  psychoses,  hypnotic  states,  and  organic  brain 
disease. 

Disturbances  of  the  Special  Senses. — The  eye  frequently  shows 
manifestations  of  general  nervous  diseases  that  are  to  some  extent 
characteristic.  Miosis  or  contraction  of  the  pupil  occurs  in  paresis, 
locomotor  ataxia,  meningitis,  brain  tumor,  disseminated  sclerosis, 
uremia,  and  other  similar  conditions;  while  mydriasis  or  dilatation 
of  the  pupil  may  be  observed  in  optic  atrophy,  paralysis  of  the 
third  nerve,  epileptic  and  hysteric  attacks,  paresis,  locomotor  ataxia, 
etc.  Unequal  pupils  may  be  seen  in  health  and  in  local  ocular  disease 
in  addition  to  paretic  dementia,  locomotor  ataxia,  and  affections 
interfering  with  the  nerve-supply  of  the  iris. 

The  Argyll-Robertson  pupil  is  that  which  fails  to  respond  to  light 
but  accommodates  for  distance.  It  is  symptomatic  of  paresis  and 
locomotor  ataxia. 

Conjugate  deviation  of  the  eyes  consists  in  outward  rotation  of  the 
eyes,  such  as  occurs  in  apoplexy  and  cerebral  convulsions  of  organic 
origin. 

Nystagmus,  or  tremor  of  the  eyeball,  when  unassociated  with 
local  ocular  disease  may  be  taken  as  an  indication  of  disseminated 
sclerosis,  Friedreich's  ataxia,  or  affections  of  the  basal  ganglia. 

Optic  neuritis,  papillitis,  or  choked  disk,  occurs  in  the  course  of 
tumors  and  cerebral  meningitis.  It  may  also  be  produced  by  Bright's 
disease,  syphilis,  anemia,  and  various  toxic  conditions. 

Primary  optic  atrophy  is  especially  significant  of  locomotor  ataxia 


532  DISEASES    OF   THE   CEREBRAL  MEMBRANES 

and  paresis.  Secondary  optic  atrophy  is  usually  due  to  inflammation, 
injury,  tumor,  etc.,  of  the  optic  nerve. 

The  ear  is  also  affected  in  the  discharge  of  its  function  in  certain 
nervous  diseases  but  to  a  less  extent.  Deafness  may  be  due  to 
affections  of  the  auditory  nerve  in  some  part  of  its  course  but  is 
usually  secondary  to  some  local  condition.  Exaggeration  of  the 
hearing  occurs  in  cerebral  hyperemia  and  hysteria.  Tinnitus  aurium, 
or  ringing  in  the  ears,  arises  from  local  ear  disease,  cerebral  hyperemia 
and  anemia,  and  jMeniere's  disease,  and  after  the  use  of  certain 
drugs,  such  as  quinine  and  its  derivative  and  the  salicylates  in  excess. 

Diseases  of  the  Nervous  System  may  be  conveniently  studied 
under  the  following  headings: 

I.  Diseases  of  the  Cerebral  Membranes.  II.  Diseases  of  the 
Cerebrum.  III.  Diseases  of  the  Spinal  Cord.  IV.  Diseases  of  the 
Nerves.     V.   General   Nervous   Diseases. 

DISEASES  OF  THE  CEREBRAL  MEMBRANES 

Clinically,  the  brain  is  invested  with  only  two  membranes:  (i) 
dura  mater,  and  (2)  the  pia  mater,  or  pia-arachnoid. 

The  dura  lines  the  interior  of  the  skull,  and,  in  addition,  supports 
and  protects  the  brain.  The  falx  cerebri  is  an  extended  process 
of  the  dura  which  extends  into  the  longitudinal  fissure  and  separates 
the  two  cerebral  hemispheres;  the  tentorium  is  a  process  of  the  dura 
separating  the  cerebrum  and  the  cerebellum;  the  falx  cerehelli  is  a 
process  of  the  dura  extending  between  the  two  hemispheres  of  the 
cerebellum. 

The  blood  supply  for  the  dura  is  from  the  anterior,  middle,  and 
posterior  meningeal  arteries.  The  middle  meningeal  or  medidural 
artery,  a  branch  of  the  internal  maxillary,  is  the  largest  of  the  three, 
and  is  the  vessel  usually  involved  in  meningeal  hemorrhage. 

The  nerve  supply  (a  mooted  question)  is  undoubtedly  received 
from  the  fifth  or  trigeminus  pair  of  cranial  nerves,  irritation  of  which 
nerve-supply  may  produce  hyperesthesia,  pain,  reflex  motor  and 
vaso-motor  disturbances  (Duret). 

The  pia  (which  includes  the  arachnoid,  after  the  suggestion  of 
Tuke,  and  which  Mills  calls  the  arachnopia,  or  pia-arachnoid)  is 
composed  of  two  layers — the  visceral  layer  and  the  parietal  layer. 
This  membrane  is  a  vascular  network  held  by  connective  tissue. 
The  visceral  layer  of  the  pia   (formerly  known  as  the  pia  alone) 


PACHYMENINGITIS  533 

closely  invests  the  brain  everywhere,  dipping  into  the  fissures  and 
into  the  ventricles.  The  parietal  layer  (formerly  known  as  the 
arachnoid)  closely  covers  the  dura  in  all  its  parts. 

The  pia-arachnoid  is  the  nutritive  covering  of  the  brain,  supplying 
a  considerable  section  with  blood.  The  vessels  of  the  pia  lie  on  the 
surface  and  are  encased  in  perivascular  sheaths  composed  of  the 
denser  portions  of  the  membrane.  These  perivascular  spaces  are 
the  lymph-canals  accompanying  the  blood-vessels  into  the  brain- 
substance  and  communicating  with  the  subarachnoid  spaces  or 
cisterns. 

The  nerve-supply  of  the  pia-arachnoid  is  still  in  dispute,  the 
membrane  being  generally  considered  without  sensation.  This  is 
probably  an  error. 

The  Pacchionian  granulations  are  always  present  in  abundance 
''on  the  outside  of  the  dura,  on  its  inner  surface,  on  the  arachno-pia, 
and  within  the  superior  longitudinal  sinus  and  the  parasinusoidal 
spaces.  They  often  indent  the  calvarium,  and  in  rare  instances 
they  penetrate  it.  It  is  generally  conceded  that  they  are  enlarge- 
ments of  the  normal  villi  or  tuft-like  elevations  of  the  parietal  layer 
of  the  pia  (arachnoid).  Repeated  attacks  of  meningeal  hyperemia 
probably  assist  in  their  development."     (Mills.) 

The  term  pachymeningitis  means  inflammation  of  the  dura  mater; 
leptomeningitis  is  inflammation  of  the  pia  and  arachnoid;  when  the 
word  meningitis  is  used  alone,  leptomeningitis  is  usually  meant. 
When  some  of  the  symptoms  of  meningitis  are  present,  but  no  organic 
lesion  is  recognized,  the  condition  is  known  as  meningismus. 

PACHYMENINGITIS 

Synonyms. — Meningitis;  inflammation  of  the  dura  mater. 

Definition. — Inflammation  of  the  dura  mater;  when  the  external 
layer  is  primarily  involved,  it  is  termed  pachymeningitis  externa; 
when  the  internal  layer  is  primarily  involved,  it  is  termed  pachy- 
meningitis interna. 

Causes. — Pachymeningitis  externa  is  a  surgical  malady,  resulting 
from  fractures,  penetrating  wounds,  and  other  injuries  of  the  skull. 

Pachymeningitis  interna  may  be  due  to  blows  upon  the  head 
without  injury  to  the  skull,  chronic  alcoholism,  scurvy.  Bright 's 
disease,  tuberculosis,  and  syphilis.  Chronic  internal  otitis  and 
supp.urative  inflammation  of  the  orbit  may  cause  it,  as  may  also 
inflammation  in  the  venous  sinuses  the  result  of  a  thrombus  under- 


534  PACHYMENINGITIS 

going  suppurative  changes.  Erysipelas,  sun-stroke,  and  gout  are 
recorded  causes. 

Pathological  Anatomy. — Pachymeningitis  interna  begins  with  hy- 
peremia of  the  membrane,  followed  by  an  exudation  which  develops 
into  a  membranous  new  formation,  containing  a  great  number  of 
vessels  of  considerable  size,  but  having  very  thin  walls.  Hemor- 
rhages from  these  new  vessels  are  of  frequent  occurrence,  which  in- 
crease the  size  and  thickness  of  the  newly  formed  membrane. 

The  usual  position  of  the  neo-membrane  or  new  formation  is  on 
the  upper  surface  of  the  hemispheres,  extending  downward  toward 
the  occipital  lobe.  The  changes  in  the  adjacent  portion  of  the  brain 
are  dependent  on  the  size  and  thickness  of  the  neo-membrane. 
Bartholow  observed  a  case  in  which  the  ''cyst"  was  ^i  inch  in  thick- 
ness at  its  thickest  part,  and  it  depressed  the  hemisphere  correspond- 
ingly, the  convolutions  being  flattened,  the  sulci  almost  obliterated, 
and  the  ventricle  lessened  one-half  in  size. 

In  pachymeningitis  syphilitica,  the  pathological  lesion  is  in  the 
form  of  gummatous  tumors  or  masses  w^hich  may  degenerate  and 
become  either  cheesy  masses  or  be  converted  into  a  purulent -looking 
fluid. 

In  old  age  the  dura  mater  becomes  thick,  cartilaginous,  and  of  a 
dull  white  color.     The  sheaths  of  the  arteries  are  also  thickened. 

Symptoms. — These  are  very  obscure  and  are  principally  those  of 
cerebral  compression.  Persistent  headache,  vertigo,  photophobia, 
insomnia,  and  gradual  impairment  of  intellect  and  locomotion  fol- 
lowed by  delirium,  convulsions,  and  coma,  or  by  apoplectic  attacks 
and  paralysis,  occurring  in  the  aged  or  those  in  whom  any  of  the 
already-mentioned  causes  exist,  should  lead  the  examiner  to  suspect 
inflammation  of  the  dura  mater.  Epileptic  attacks  sometimes 
occur  in  this  condition.  Circumscribed  painful  edema  behind  the 
ear  and  less  fullness  of  the  corresponding  side  are  indicative  of  throm- 
bosis of  the  transverse  sinus,  a  condition  nearly  always  accompanied 
by  pachymeningitis. 

Diagnosis. — The  diagnosis  is  always  diflEicult  and  frequently  im- 
possible on  account  of  the  obscurity  of  the  symptoms^  Many  cases 
are  recognized  only  at  autopsy. 

Prognosis. — The  outlook  is  unfavorable  in  all  forms.  In  trau- 
matic cases,  surgical  intervention  offers  some  hope  of  cure. 

Treatment. — Pachymeningitis  externa  is  to  be  treated  surgically. 
Trephining  is  indicated  in  some  cases.     It  is  claimed  that  benefit 


ACUTE    LEPTOMENINGITIS  535 

has  followed  a  thorough  course  of  potassium  iodide.  In  the  great 
majority  of  cases,  however,  all  that  can  be  done  is  to  treat  symptoms 
as  they  arise. 

ACUTE  LEPTOMENINGITIS 

Synonyms. — Acute  meningitis;  cerebral  fever;  arachnitis. 

Definition. — An  acute  exudative  inflammation  of  the  cerebral 
pia  mater  and  arachnoid  membranes  (pia  arachnoid,  or  arachnopia), 
usually  limited  to  the  convexity  of  the  cerebrum;  characterized  by 
fever,  vomiting,  headache,  and  delirium,  followed  by  symptoms  of 
general  collapse. 

Causes. — It  may  occur  during  the  course  of  the  infectious  fevers, 
especially  erysipelas,  typhoid  fever,  influenza,  pneumonia,  and 
diphtheria,  or  it  may  follow  middle-ear  disease  and  injury  or  disease 
of  the  cranial  bones.  It  may  be  secondary  to  some  tuberculous 
focus  elsewhere  in  the  body  or  to  disease  of  other  serous  membranes. 
Among  other  causes  may  be  mentioned  cerebral  overwork,  prolonged 
wakefulness,  acute  alcoholism,  exposure  to  the  sun,  and  syphilis. 
In  rare  instances  the  disease  may  occur  as  an  independent  affection. 
The  condition  occurs  most  frequently  in  children  and  young  adults, 
affecting  males  more  often  than  females. 

The  exciting  cause  is  a  microorganism.  In  the  primary  variety, 
the  diplococcus  intracellularis  meningitidis  is  the  exciting  cause;  in 
the  secondary  forms,  the  microorganism  with  which  the  underlying 
cause  is  associated,  especially  the  pneumococcus,  streptococcus, 
typhoid  bacillus,  tubercle  bacillus,  and  the  diphtheria  bacillus  (and 
see  table  on  page  31). 

Pathological  Anatomy. — The  inflammatory  changes  may  be  limited 
to  the  convexity  or  to  the  base  of  the  brain  but  more  frequently 
both  portions  are  involved.  The  earliest  change  is  hyperemia 
which  is  soon  followed  by  turbidity  and  opacity  of  the  affected 
membrane.  As  the  process  advances  a  seropurulent,  purulent,  or 
fibrinous  exudate  is  formed  which  distends  the  subarachnoid  space 
and  may  fill  the  ventricles  thereby  compressing  and  flattening  the 
convolutions.  The  condition  may  extend  to  the  brain  substance. 
When  due  to  some  general  infection  the  inflammation  is  more  or 
less  difftised  over  the  entire  brain,  but  when  secondary  to  some  local 
infection  as  middle-ear  disease  and  tuberculosis,  it  is  basilar  and  to 
some  extent  circumscribed.  The  tuberculous  form  is  characterized 
by  the   formation   of  small   tubercles   and   a  yellowish   gelatinous 


536  ACUTE   LEPTOMENINGITIS 

material.     When  the  ventricular  effusion  is  very  great  it  constitutes 
acute  hydrocephalus. 

Symptoms. — The  onset  may  be  sudden  but  is  usually  gradual, 
accompanied  by  such  prodromes  as  persistent  headache,  vertigo, 
irritability  of  temper,  vomiting  without  nausea,  feverishness,  coated 
tongue,  and  constipation.  These  symptoms  may  continue  from  a 
few  hours  to  two  or  three  days. 

The  stage  of  invasion  is  manifested  by  chill,  high  fever,  103°  to 
i04°F._,  rapid  pulse,  100  to  120,  flushed  face,  congested  eyes,  intense 
continuous  headache,  ringing  in  the  ears,  photophobia,  vertigo, 
nausea,  aggravated  vomiting,  delirium,  and  general  cutaneous 
hyperesthesia. 

The  stage  of  excitation  is  characterized  by  increased  cutaneous 
sensibility,  increased  sensitiveness  to  light  and  sound,  furious  de- 
lirium often  resembling  mania,  continual  jerking  of  the  limbs,  oscil- 
lation of  the  eyeballs  (nystagmus),  twitching  of  the  facial  and  other 
muscles,  retraction  of  the  head,  arching  backward  of  the  body,  and 
sometimes  convulsions.  The  pulse  is  slow  and  irregular,  and  the 
fever  is  high.  Headache  continues  and  may  be  subject  to  exacerba- 
tions during  w^hich  the  patient  cries  out  in  a  peculiar  manner  {the 
hydrocephalic  cry).  Coated  tongue,  constipation,  and  retraction 
of  the  abdomen  are  present.  The  finger  drawn  across  the  abdomen 
leaves  a  red  line,  the  tache  cerebrate.  The  duration  of  this  stage  is 
from  one  day  to  one  or  two  weeks. 

The  stage  of  depression  or  collapse  appears  as  the  exudate  accumu- 
lates in  sufficient  quantities  to  induce  marked  pressure  and  is  mani- 
fested largely  by  paralytic  phenomena.  The  patient  gradually 
becomes  more  quiet,  the  muscular  agitation  and  delirium  subsiding. 
Somnolence  develops  and  passes  into  coma;  at  times  there  is  tempor- 
ary consciousness  soon  followed  by  coma.  The  pulse  is  slow  and 
irregular  and  the  fever  is  lessened.  Various  palsies  such  as  strabis- 
mus, ptosis,  paralysis  of  pupillary  reaction,  and  relaxation  of  the 
sphincters  are  present.  Cutaneous  anesthesia,  blindness,  deafness, 
and  Cheyne-Stokes  breathing  eventually  supervene.  Death  ulti- 
mately follows,  being  ushered  in  with  convulsions  or  coma  with 
cyanosis. 

Diagnosis. — The  characteristic  symptoms  of  acute  leptomeningitis 
are  rapidly  developed  headache,  vomiting  unassociated  with  nausea 
or  gastric  trouble,  fever,  and  delirium. 

Cerebrospinal  meningitis  may  be   distinguished  by  the  marked 


ACUTE    LEPTOMENINGITIS  537 

Spinal  symptoms,  the  eruption,  the  presence  of  the  diplococcus 
intracellularis  meningitidis  in  the  fluid  withdrawn  by  lumbar  punc- 
ture, Kemig's  sign  and  its  occurrence  in  epidemics. 

Tuberculous  meningitis  is  attended  by  symptoms  referable  to 
disease  at  the  base  of  the  brain  and  by  the  symptoms  of  tuberculosis 
elsewhere  in  the  body.     Its  onset  is  slow  (and  see  page  540). 

Cerebral  complications  in  typhoid  fever,  typhus  fever,  rheumatism , 
pneumonia,  etc.,  may  be  confused  with  acute  leptomeningitis,  but  a 
careful  study  of  the  history,  symptoms,  etc.,  will  serve  to  make  a 
distinction. 

Uremia  differs  from  acute  leptomeningitis  in  that  the  face  is  turgid 
and  edematous,  the  eyelids  are  puffy,  albuminuria  is  constant,  an 
irregular  temperature  is  present,  and  convulsions  are  common, 
while  in  leptomeningitis  the  face  is  pale,  edema  is  absent,  albuminuria 
seldom  occurs,  and  the  attack  begins  with  chills  followed  by  fever. 

Delirium  tremens  is  characterized  by  busy  delirium,  the  patient 
imagining  that  he  is  surrounded  with  persons  and  animals  and 
is  wild  in  his  gestures  and  utterances;  the  temperature  is  normal  or 
subnormal  and  the  skin  is  wet  and  clammy.  In  leptomeningitis 
the  delirium  is  mild  but  incoherent,  the  surface  is  hot  and  dry  and 
there  is  severe  vomiting  and  headache. 

Prognosis. — The  outlook  is  very  unfavorable.  If  recognized  early 
and  treated,  a  fair  number  of  recoveries  occur,  but  it  usually  leaves 
the  patient  subject  to  attacks  of  epilepsy  or  with  a  persistent  head- 
ache, and  more  or  less  mental  impairment.  Blindness  and  chronic 
internal  hydrocephalus  are  rare  results.  The  duration  is  from  a  few 
days  to  two  or  more  weeks. 

Treatment. — Keeping  in  view  the  course  and  general  prognosis 
of  leptomeningitis,  it  is  questionable  if  any  very  active  medication 
will  abate  the  disease  during  any  stage.  Absolute  rest  in  a  quiet, 
well  ventilated  room  with  the  head  elevated  will,  however,  serve  to 
lessen  the  severity  of  the  symptoms.  The  diet  should  be  liquid  in 
character;  all  the  secretions  should  receive  attention;  and  an  ice-bag 
should  be  applied  to  the  head  to  relieve  the  intense  headache.  In 
vigorous  or  sthenic  cases,  with  high  febrile  reaction  and  exaggeration 
of  the  early  symptoms,  venesection  or  leeches  behind  the  ears,  to  the 
temples,  or  in  the  nuchal  region  may  be  employed,  followed  by  the 
application  of  cold  and  the  internal  administration  of  fluidextract  of 
ergot  in  large  doses  every  two  hours.  The  cerebral  circulation  may 
be  markedly  influenced  by  compression  of  the  carotids.     Vomiting 


538  TUBERCULOUS   MENINGITIS 

may  be  satisfactorily  relieved  in  nearly  all  cases  by  the  use  of  hydrated 
chloral,  gr.  iij  to  v  (0.2  to  0.3  gm.),  diluted,  every  half -hour  by  the 
mouth  until  relieved,  or  in  doses  of  from  gr.  x  to  xv  (0.6  to  i  gm.)  by 
the  rectum.  The  restlessness,  convulsions,  delirium,  etc.,  require 
the  use  of  morphine,  bromides,  chloral,  phenacetin,  and  similar 
drugs.  Temperature  may  be  reduced  by  hydrotherapy.  The 
course  of  the  disease  may  be  greatly  influenced  by  lumbar  puncture. 
The  various  preparations  of  mercury  are  often  of  great  value,  par- 
ticularly in  chronic  cases.  In  the  late  stages,  tonics  and  stimulants 
should  be  freely  given  combined  with  the  use  of  potassium  iodide  and 
iodide  of  iron,  and  the  application  of  flying  blisters. 

TUBERCULOUS  MENINGITIS 

Synonjrms. — Basilar  meningitis;  acute  hydrocephalus. 

Definition. — An  inflanmiation  of  the  leptomeninges  (pia-arach- 
noid),  particularly  the  basal  pia-mater,  attended  with  or  due  to 
the  deposit  of  gray  miliary  tubercle,  characterized  by  gradual  decline 
of  the  bodily  and  mental  powers  in  addition  to  symptoms  referable 
to  meningeal  inflammation. 

Causes. — It  usually  occurs  as  a  secondary  affection;  commonly  a 
sequel  to  tuberculous  disease  of  some  other  organ.  It  is  observed 
most  frequently  in  children  between  two  and  six  years  of  age,  al- 
though numerous  cases  are  reported  as  having  occurred  between  the 
ages  of  twenty  and  thirty  years.  The  influence  of  the  scrofulous 
diathesis,  so-called,  in  the  production  of  this  affection  is  very  great. 
The  '^gelatinous  children  of  albuminous  parents,"  as  the  phrase 
goes,  possess  a  special  susceptibility  for  tuberculous  meningitis. 

Pathological  Anatomy. — The  deposition  of  tubercle  usually  occurs 
at  the  base  of  the  brain.  Depositions  of  grayish-white  granules  of  a 
translucent,  somewhat  gelatinous  appearance — miliary  tubercle — 
are  distributed  along  the  vessels  of  the  pia  mater,  resulting  in  inflam- 
mation and  the  exudation  of  lymph,  with  the  consequent  thickening 
and  opacity  of  the  membranes.  The  cerebral  tissue  is  not  usually 
involved,  although  on  section  the  lines  indicative  of  blood-vessels 
are  very  much  increased  in  number.  The  ventricles  are  distended  by 
a  turbid,  or  milky,  or  even  bloody  serum,  containing  excess  of  albu- 
min and  an  increased  number  of  lymphocytes;  occasionally  tubercle 
bacilli  are  found.  The  presence  of  the  tubercles  alone  may  give  rise 
to  no^symptoms  until  the  exudative  products  of  the  resultant  inflam- 
mation develop.  - 


TUBERCULOUS    MENINGITIS  539 

Tuberculous  deposits  oceur  also  in  the  lungs,  intestines,  and  at 
times,  in  other  organs. 

Symptoms. — The  onset  may  be  sudden  or  gradual.  Convulsions 
may  usher  in  the  attack.  Prodromal  symptoms  are  usually  present. 
The  child  becomes  irritable  and  there  are  present  anorexia,  loss  of 
flesh,  swelling  of  the  abdomen,  constipation  alternating  with  diarrhea, 
irregular  periods  of  fever  with  grinding  of  the  teeth,  and  sleepless- 
ness. Headache  occurs  as  is  shown  by  the  child,  even  when  at 
play,  stopping  and  resting  its  head  on  its  hand  or  on  the  floor.  The 
duration  of  this  stage  is  from  one  week  to  one  or  two  months. 

The  stage  of  excitation  begins  suddenly  with  obstinate  vomiting, 
severe  headache,  convulsions,  fever,  102°  to  io3°F.,  in  the  evening; 
falling  to  99°F.,  in  the  morning,  and  a  soft  and  compressible,  irregular 
pulse.  On  drawing  the  finger  nail  lightly  over  the  surface  of  the 
body  a  red  line  results,  "the  cerebral  stain,"  of  Trousseau.  The 
special  and  general  senses  become  exalted,  resulting  in  photophobia, 
tinnitus  aurium,  intolerance  to  sound,  and  cutaneous  hyperesthesia. 
The  muscles  are  subject  to  spasmodic  contraction  and  rigidity,  at 
times  giving  rise  to  opisthotonos.  This  period  pf  the  disease  lasts 
from  two  weeks  to  a  month. 

The  stage  of  depression  follows  the  preceding  and  is  the  result  of 
the  pressure  of  the  exudation  on  the  brain.  The  pulse  is  slow  and 
compressible  and  its  rhythm  irregular.  The  temperature  becomes 
less.  A  tendency  to  somnolence  alternating  with  quiet  delirium 
soon  becomes  manifest.  There  are  also  continual  movements  of 
the  fingers,  as  in  picking  up  objects,  mental  stupor,  periodic  convul- 
sions, strabismus,  and  oscillation  of  the  eyeballs.  Intervals  of 
wakefulness  occur  during  which  the  headache  becomes  excruciating, 
causing  the  peculiar  shrill  cry  or  shriek,  ''the  hydrocephalic  cry." 
These  are  associated  with  contraction  of  the  facial  muscles  as  if 
intense  suffering  were  experienced.  Collapse  finally  occurs  with 
Cheyne-Stokes  breathing  and  deepening  coma  which  eventually 
terminates  in  death  with  or  without  convulsions.  The  duration 
of  this  stage  is  from  one  or  two  days  to  a  week. 

Diagnosis. — Acute  leptomeningitis  and  tuberculous  meningitis  have 
closely  analogous  symptoms  during  the  stage  of  excitation,  but  the 
history  and  clinical  course  of  the  two  maladies  determine  the  diag- 
nosis. The  following  table  (from  Wheeler  and  Jack)  will  be  of 
service : 


540 


DISEASES    OF   THE    CEREBRUM 


Simple   meningitis 


Tuberculous  meningitis 


Age. — Any  age 

Cause. — ilnjury  or  local  causes,  fevers,  etc .  .  . 

Course. — Short 

Convulsions. — May  be  present 

Abdomen. — Nothing  marked 

Pathology. — i.  That  of  simple  or  suppurative 
inflammation. 

2.  Attacks  convexity  of  brain 

3.  Ventricles  not  distended 

Prognosis. — Almost  hopeless 


Young  children  and  young  adults. 

No  local  cause,  but  symptoms  of  tubercle 
elsewhere. 

Longer  than  simple,  especially  the  pro- 
dromal stage. 

Common,  even  during  the  compression 
stage,  often  precede  death. 

Markedly  retracted.^ 

That  which  is  associated  with  the  pres- 
ence -  of  tubercle,  and  formation  of 
peculiar  greenish  pus. 

2.  Attacks  the  base  of  brain. 

3.  Ventricles  are  distended,   and  may 
cause  hydrocephalus. 

Depends  on  cause  and  extent. 


Prognosis. — Unfavorable.  The  usual  duration  is  three  or  four 
weeks  after  fully  developed  prodromes.  If  ushered  in  by  convul- 
sions, the  duration  is  shorter. 

Treatment. — There  are  no  means  of  retarding  the  disease.  The 
measures  recommended  under  Acute  Leptomeningitis  may  be  of 
service  in  rendering  the  patient  more  comfortable.  Cod-liver  oil, 
syrup  of  the  iodide  of  iron,  syrup  of  hydriodic  acid,  and  quinine 
should  also  be  administered. 


DISEASES  OF  THE  CEREBRUM 

To  -ui-L(ierstand  the  symptoms  in  diseases  of  the  nervous  system, 
a  clear  and  precise  knowledge  of  the  anatomy  and  physiology  is 
necessary.  Presuming  this  knowledge,  only  a  very  few  of  the  most 
elementary  facts  will  be  mentioned  before  discussing  diseases  of  the 
brain  and  cord. 

The  nerve-cell  is  the  real  foundation  of  the  nervous  system.  It 
receives  its  nourishment  from  the  arterioles  and  the  lymphatics, 
and  is  drained  by  the  venules,  as  are  other  tissues,  and  is  supported 
by  the  connective  tissue  known  as  neuroglia.  Each  nerve-cell  has 
two  kinds  of  processes,  the  axis  cylinder  process  and  the  protoplasmic 
process;  the  three — the  cell  and  the  two  processes — are  known  as  the 
neuron,  the  entire  nervous  system  being  made  up  of  neurons.  The 
axis-cylinder  processes  conduct  the  nerve  impressions  or  current 
from  the  cells.  The  protoplasmic  process  conducts  the  nervous 
current  or  impressions  into  the  cell,  and  it  is  through  these  processes 
and  their  collaterals  that  the  cell  is  brought  into  communication 
with  all  portions  of  the  body.     The  nerve-cells — "the  very  inner 


DISEASES    OF   THE   CEREBRUM 


541 


citadel  of  nervous  life" — are  mainly  set  in  the  gray  matter  of  the 
brain  and  the  spinal  cord,  and  the  axis-cylinder  processes  and  the 
protoplasmic  processes  run  in  bundles  or  collections  in  the  white 
matter  of  the  brain  and  spinal  cord.  The  gray  matter  of  the  brain 
and  spinal  cord,  or  the  nerve-cells,  is  found  chiefly  in  the  cortex  of 
the  cerebrum  and  the  basal  ganglia,  in  the  cortex  of  the  cerebellum, 
in  the  horns  of  the  spinal  cord,  and  in  the  nuclei  of  the  medulla 
oblongata,  and  all  these  masses  of  gray  matter  or  cells  are  connected 
by  nerves,  or  white  matter,  each  protected  by  connective  tissue. 
The   cells   endow   the   nerves   with   their  particular  functions.     A 


Fig.  58. — Localization  of  function   on  the  cerebral  cortex;   external  surface  (Starr). 
{From  Woolsey's  Surgical  Anatomy.) 

knowledge  of  the  physiology  of  the  nervous  system  is  essential  in 
order  to  understand  the  alterations  in  the  functions  of  the  different 
masses  of  gray  matter,  or  cells,  and  of  the  nerves,  or  white  matter. 

A  knowledge  of  the  blood-supply  of  the  brain  is  of  great  practical 
importance,  and  particularly  for  the  understanding  of  the  symptoms 
and  pathology  of  apoplexy  and  cerebral  embolism. 

The  external  carotids  on  each  side  supply  blood  to  the  scalp,  the 
skull,  and  the  dura  mater. 

The  internal  carotid  artery  on  each  side,  and  the  vertebral  arteries 
supply  the  brain,  pia  mater,  and  the  eyes. 

The  internal  carotid  arteries  divide  into  the  anterior  cerebral  and 
the  middle  cerebral  arteries. 


542  DISEASES    OF    THE    CEREBRUM 

The  vertebral  arteries  on  each  side  give  off  the  inferior  cere- 
bellar arteries,  and  then  join  and  form  the  basilar  artery,  which 
divides,  forming  the  two  posterior  cerebral  arteries,  which,  in  turn, 
give  off  a  posterior  communicating  artery.  It  is  the  union  of  these 
cerebral  arteries  by  the  anterior  and  posterior  communicating  arte- 
ries that  forms  the  circle  of  Willis.  From  various  portions  of  the 
circle  of  Willis  and  the  beginnings  of  the  anterior,  middle,  and  poste- 
rior cerebral  arteries  are  given  off  six  groups  of  vessels,  which  furnish 
the  blood-supply  to  the  basal  ganglia  and  the  adjacent  white  matter, 
from  which  they  derive  their  name,  "the  central  arteries  of  the  brain." 
The  "central  arteries"  given  off  by  the  middle  cerebral  or  Sylvian 
artery  are  of  the  most  importance  to  the  clinician.  They  are  known 
as  the  lenticular-optic  and  the  lenticular-striate  arteries,  and  are 
usually  involved  in  cerebral  hemorrhage. 

Without  a  knowledge  of  the  known  centers  of  "localization"  it  is 
impossible  to  interpret  the  symptoms  of  diseases  of  the  nervous 
system. 

The  motor  area  is  entirely  in  front  of  the  fissure  of  Rolando.  "All 
diseases  which  destroy  any  considerable  portion  of  this  cortical 
area  invariably  produce  paralysis  of  the  opposite  half  of  the  body; 
while,  no  matter  how  extensive  the  destructive  process  elsewhere  in 
the  cortex,  motion  remains  intact  if  this  is  not  touched."  This 
region  may  be  further  "localized"  for  separate  groups  of  muscles. 

The  center  for  muscular  sense  is  believed  to  be  located  largely  in 
the  parietal  lobe. 

The  sensory  areas  are  located  in  the  cortex;  their  exact  situation 
is  not  absolutely  proved,  but  they  are  believed  to  be  posterior  to  the 
motor  areas. 

The  auditory  center  is  located  in  the  first  temporal  gyrus. 

The  visual  center  is  in  the  occipital  lobe  and  its  cortical  area  in  the 
cuneus  and  adjacent  convolutions. 

The  speech  center  (Broca's  center)  is  located  in  the  posterior  part 
of  the  third  left  frontal  convolution  (Broca's  convolution)  in  right- 
handed  individuals  and  in  the  similar  convolution  on  the  right  side 
in  left-handed  persons.  The  various  phenomena  resulting  from 
injury  or  disease  of  this  area  are  termed  collectively  aphasia.  Tyson 
describes  it  as  a  loss  of  power  to  comprehend  words  correctly  and  to 
use  them  properly.  It  may  be  subdivided  into  mind-blindness, 
apraxia,  word-blindness,  alexia,  loss  of  memory  for  words,  amnesia^ 
word-deafness,  etc. 


CONGESTION   OF   THE  BRAIN  543 

The  ''mind''  center  has  long  been  considered  as  located  in  the 
frontal  lobe,  anterior  to  the  motor  area  and  the  third  frontal  convolu- 
tion, but  of  late  the  view  is  growing  that  for  complete  integrity  of 
the  mind  the  entire  cortex  must  be  intact,  although  lesions  of  the 
portions  named  produce  mental  symptoms  only,  while  lesions  of 
other  portions  of  the  cortex  cause  other  disorders  in  which  mental 
changes  are  more  or  less  prominently  observed. 

The  many  symptoms  resulting  from  diseases  of  the  brain  can  be 
placed  in  four  groups: 

(i)  General  symptoms  of  brain  irritation.  (2)  General  symptoms 
of  brain-pressure.  (3)  Symptoms  of  focal  irritation  or  destruction. 
(4)  Symptoms  due  directly  to  the  pathological  process. 

Symptoms  of  brain  irritation,  or  hyperemia,  are:  headache,  vertigo, 
vomiting,  photophobia,  mental  irritability,  insomnia,  fullness  or 
pressure  over  the  brain,  with  scalp  tenderness  and  noises  in  the  ears. 
Rarely  convulsive  symptoms  and  delirium  may  occur. 

Symptoms  of  brain-pressure  are:  headache,  vomiting,  mental  dull- 
ness, and  frequently  some  form  of  paralysis  with  contracted  pupil 
and  finally  coma. 

Focal  symptoms  depend  on  the  character  of  the  lesions;  if  irritative, 
convulsive,  or  spasmodic  phenomena;  if  located  in  the  motor  area 
and  if  decided  pressure  or  destructive  lesions,  paralysis,  suc^  as 
hemiplegia,  and  aphasia. 

The  symptoms  of  brain  lesions  due  to  the  pathological  process,  itself, 
have  few  if  any  particular  symptoms  other  than  those  due  to  the 
location,  except  in  abscess,  when  the  constitutional  symptoms  of 
suppuration,  such  as  chills,  fever,  sweats,  and  prostration,  are  added 
to  other  brain  symptoms. 

CONGESTION  OF  THE  BRAIN 

Synonyms. — Cerebral  hyperemia;  cerebral  congestion. 

Definition. — -An  abnormal  fullness  of  the  vessels  (capillaries)  of 
the  brain:  Active,  when  arterial  fullness;  passive,  when  venous  fullness; 
characterized  by  headache,  vertigo,  disorders  of  the  special  senses, 
and,  if  the  hyperemia  be  decided,  convulsions. 

Causes. — Active.  Increased  cardiac  action,  the  result  of  hyper- 
trophy of  the  left  ventricle;  general  plethora;  excesses  in  eating  and 
drinking;  acute  alcoholism;  sunstroke;  inhalation  of  amyl  nitrite; 
prolonged  mental  labor;  diminished  amount  of  arterial  blood  in 


544  CONGESTION    OF    THE  BRAIN 

other  parts;  compression  of  the  abdominal  aorta  or  Hgation  of  a 
large  artery,  or  the  suppression  of  an  habitual  bleeding  hemorrhoid, 
are  the  principal  causes. 

Passive.  Dilatation  of  the  right  side  of  the  heart;  pressure  upon 
the  veins  returning  the  cerebral  blood;  emphysema;  and  similar 
conditions  interfering  with  the  venous  circulation. 

Pathological  Anatomy. — The  post-mortem  appearances  are :  Over- 
loading of  the  venous  sinuses  and  of  the  meningeal  vessels,  including 
the  finer  branches;  the  pia  mater  appears  vascular  and  opaque; 
the  gray  matter  of  the  convolutions  unduly  red;  the  convolutions 
may  be  compressed  and  the  ventricles  contracted  with  the  displace- 
ment of  a  corresponding  amount  of  cerebrospinal  fluid.  Long- 
continued  or  repeated  congestions  lead  to  enlargement  and  tortuosity 
of  all  the  vessels,  a  moist  and  slimy  condition  (edema)  of  the  cerebral 
substance,  and  an  increase  in  the  subarachnoid  fluid. 

Symptoms. — "Rush  of  blood  to  the  head"  may  be  gradual  or 
sudden  in  its  onset,  the  symptoms  aggravated  by  the  recumbent 
position.  Headache,  with  paroxysmal  neuralgic  darts,  disorders 
of  vision  and  hearing,  buzzing  in  the  ears  and  sparks  before  the  eyes, 
contracted  pupils,  vertigo,  blunted  intellect,  inability  to  concentrate 
the  mind,  irritable  temper,  and  curious  hallucinations  are  present. 
The  face  is  red,  the  eyes  congested,  and  the  carotids  pulsating. 
The  sleep  is  disturbed  by  dreams  and  jerkings  of  the  limbs.  If 
the  attack  be  sudden  (apoplectiform),  unconsciousness  with  muscular 
relaxation  will  occur. 

Cerebral  hyperemia  in  children  often  presents  alarming  symptoms, 
such  as  great  restlessness,  insomnia,  night-terrors,  gnashing  of  the 
teeth  during  sleep,  vomiting,  contraction  of  pupils  followed  by  general 
convulsion,  etc.  Any  or  all  of  these  symptoms  may  continue  more 
or  less  marked  from  an  hour  or  two  to  a  day,  the  child  enjoying  its 
usual  health,  after  a  sound  sleep,  save  a  feeling  of  fatigue. 

Prognosis. — Mild  cases  terminate  favorably  in  a  few  hours  to  a 
day  or  two,  but  show  a  strong  tendency  to  recur.  Severe  cases 
(apoplectiform)  may  terminate  in  health,  but  usually  foretell  cerebral 
hemorrhage.  The  passive  form  is  controlled  by  the  lesions  giving 
rise  to  it. 

Treatment. — Active  form.  The  cause  should  be  removed  if 
possible.  Elevate  the  head  and  apply  cold,  either  cold  cloths  or  the 
ice-cap;  at  the  same  time  warmth  to  the  feet.  Leeches  to  the  mas- 
toid, or  cups  to  the  neck,  or  in  the  apoplectiform  variety  venesection 


CEREBRAL   ANEMIA  545 

should  be  employed,  to  dimmish  the  intracranial  blood-pressure; 
compression  of  the  carotids,  or  ligatures  about  the  thighs,  have  been 
recommended. 

Active  purgation  is  indicated  either  by  croton  oil  or  magnesium 
sulphate,  by  the  mouth.     The  following  enema  is  often  valuable: 

I^.      Magnesii  sulphatis §ij  60  gm. 

Glycerini f  5J  30  c.c. 

Aquae  bul f  giv  120  c.c. 

M.   S. — Administer  slowly  per  rectum,  with  little  force. 

In  mild  cases  the  application  of  an  ice-cap  to  the  head,  a  sinapism 
to  the  nucha,  and  potassium  bromide,  gr.  xxx  to  xl  (2  to  2.6  gm.), 
repeated  and  the  enema  mentioned  above,  control  the  symptoms. 
Fluidextract  of  ergot  is  strongly  recommended,  but  its  value  seems 
to  be  overestimated. 

In  severe  cases  with  forcible,  overacting  heart,  tincture  of  aconite 
or  veratrum  viride  may  be  used  in  addition  to  the  measures  already 
mentioned. 

Passive  form.  The  treatment  should  be  directed  entirely  toward 
the  condition  producing  the  venous  stasis. 

CEREBRAL  ANEMIA 

Definition. — An  abnormal  decrease  in  the  quantity  of  blood  in 
the  cerebral  vessels;  general,  when  the  diminished  supply  includes 
all  the  vessels;  partial,  when  the  diminished  supply  is  limited  in 
area;  characterized  by  pallor,  headache,  vertigo,  some  loss  of  power, 
and,  rarely,  convulsions. 

Causes. — Partial  cerebral  anemia  results  from  obstruction  of  a 
vessel,  from  embolism  or  thrombosis.  General  cerebral  anemia  re- 
sults from  hemorrhages,  wasting  diseases,  during  convalescence  from 
severe  attacks  of  fevers,  sudden  shock,  feeble  cardiac  action,  valvular 
heart  disease,  and  general  anemia. 

Pathological  Anatomy. — The  functional  activity  of  the  brain  de- 
pends upon  the  quantity  and  quality  of  the  blood  circulating  in  the 
cerebral  capillaries.  Any  decrease  in  the  normal  quantity  or  im- 
pairment in  the  quality  produces  the  symptoms  of  cerebral  anemia. 
The  brain  is  pale  and  milky  in  color,  and  on  transverse  section  there 
are  no  bloody  points;  the  ventricles  and  perivascular  lymph-spaces 
are  well  filled  with  fluid. 

35 


546  CEREBRAL  ANEMIA 

In  partial  anemia  the  deficiency  in  the  blood-supply  is  local  corre- 
sponding to  the  area  supplied  by  the  obstructed  vessel. 

Symptoms. — In  general  cerebral  anemia,  there  are  present  pallor, 
fainting  attacks,  vertigo  worse  on  exertion,  yawning  tendency, 
headache  relieved  by  the  recumbent  posture,  and  sometimes  con- 
vulsions. In  partial  anemia,  there  is  sudden  loss  of  power  of  a 
limited  muscular  area  which  gradually  returns  to  normal.  Cerebral 
anemia  may  be  acute  or  chronic  according  as  the  causes  are  sudden 
or  gradual  in  character. 

Diagnosis. — Cerebral  hyperemia  is  characterized  by:  Fullness 
in  the  head,  vertigo,  restlessness,  insomnia  or  disturbed  sleep,  ring- 
ing in  the  ears,  and  forgetfulness;  on  lying  down  the  symptoms 
become  worse;  hyperemia  of  the  retina  may  be  detected  by  the 
ophthalmoscope. 

Cerebral  anemia  is  characterized  by:  Pallor,  nausea,  vertigo,  yawn- 
ing, dilated  pupil,  headache,  tinnitus  aurium,  and  forgetfulness; 
on  lying  down  the  symptoms  improve;  pallor  of  the  retina  may  be 
detected  by  the  ophthalmoscope. 

Prognosis. — The  outlook  is  favorable  in  those  cases  in  which  the 
cause  may  be  removed.  In  cases^  resulting  from  severe  and  repeated 
hemorrhages,  the  prognosis  is  unfavorable. 

Treatment. — In  anemia  of  the  brain  due  to  general  anemia,  regu- 
lated diet  and  the  administration  of  iron,  arsenic,  quinine,  strych- 
nine, etc.,  should  be  prescribed.  A  certain  number  of  hours  daily 
in  the  recumbent  posture  is  of  advantage.  When  there  is  a  decided 
tendency  to  attacks  of  swooning,  quickly  acting  diffusible  stimulants 
such  as  aromatic  spirit  of  ammonia,  Hoffman's  anodyne  (spirit  of 
nitrous  ether),  nitroglycerin,  etc.,  should  be  given.  Amyl  nitrite, 
cautiously  administered,  may  be  used  at  times.  The  following 
prescription  will  be  found  of  value  in  improving  the  quantity  and 
quality  of  the  blood  in  these  cases : 

^.     Strychninae  sulph gr.  j  0.065  gm. 

Quininse  sulph gr.  xlviij  3 .  i       gm. 

Acid,  hydrochlorici  dil f5ij  8.0      c.c. 

Tinct.  gentian,  comp f  Biij  90.0      c.c. 

Tinct.  card.  comp.  q.  s.  ad  fgvj       ad  180.0      c.c. 

M.  S. — Teaspoonful  in  water,  after  meals. 

In  those  cases  due  to  heart  disease,  hemorrhages,  etc.,  the  remedial 
measures  advised  for  those  conditions  should  be  instituted  in  addition. 


CEREBRAL   HEMORRHAGE  547 

CEREBRAL  HEMORRHAGE 

Synonyms. — Apoplexy;  "a  stroke." 

Definition. — The  sudden  rupture  of  a  cerebral  vessel  and  escape 
of  blood  into  the  cerebral  tissue,  causing  pressure  and  more  or  less 
destruction  of  the  brain-substance,  characterized  by  sudden  uncon- 
sciousness, irregular,  noisy  respiration,  and  complete  muscular 
relaxation. 

Causes. — It  is  a  disease  of  the  aged,  seldom  being  encountered  in 
individuals  under  forty  years  of  age.  Apoplexy  early  in  life  is 
usually  syphilitic.  Under  ordinary  circumstances  it  seems  to  occur 
most  frequently  in  the  spring  and  autumn.  The  principal  cause  is 
disease  of  the  vessels,  manifesting  itself  in  the  development  of 
miliary  aneurysms  or  in  a  chronic  endarteritis  with  an  associated 
cardiac  hypertrophy.  As  contributory  causes  may  be  mentioned 
heredity,  Bright's  disease,  syphilis,  chronic  alcoholism,  and  the 
various  other  affections  that  induce  arterial  degeneration.  The 
condition  may  be  precipitated  by  emotion,  overexertion,  acute 
indigestion,  acute  alcoholism,  and  similar  disturbances. 

Pathological  Anatomy. — The  most  common  locations  of  cerebral 
hemorrhages  are  the  regions  supplied  by  the  "central  arteries," 
the  internal  capsule,  corpus  striatum,  and  thalamus  opticus;  less 
common,  the  cerebellum;  next  in  frequency,  the  pons  and  medulla 
oblongata,  and  rarely  on  the  convexity  of  the  brain,  termed  meningeal 
hemorrhage. 

Intracerebral  hemorrhage  is  more  common  upon  the  right  than 
upon  the  left  side,  and  especially  affects  the  region  of  the  caudate 
nucleus,  lenticular  nucleus,  internal  capsule,  and  optic  thalamus; 
and  particularly  the  outer  border  of  the  lenticular  body,  which  is 
supplied  by  the  striate  artery,  the  artery  of  cerebral  hemorrhage. 
These  lenticulo-striate  arteries  are  branches  of  the  Sylvian  artery, 
and  have  no  anastomoses.  When  the  hemorrhage  is  large,  the  blood 
may  break  into  the  ventricles  and  pass  by  the  iter  from  the  third  to 
the  fourth  ventricle.  A  recent  clot  is  dark  in  color,  and  in  consistency 
a  soft,  grumous  mass,  composed  of  coagulated  blood  and  brain 
substance  in  varying  proportions,  at  whose  center  is  the  opening 
into  the  ruptured  vessel.  The  clot  excites  inflammation  around  it, 
resulting  in  its  becoming  encysted,  by  the  development  of  new  connec- 
tive tissue  from  the  neuroglia,  and  then  being  gradually  absorbed, 
leaving  a  cicatrix;  or  the  brain-tissue  around  the  clot  softens  and 
degenerates — localized  softening. 


543  CEREBRAL  HEMORRHAGE 

Symptoms. — The  attack  may  occur  suddenly  as  an  apoplectic 
shock  or  stroke,  or  slowly  with  prodromes  or  '^warnings." 

Prodromes:  Headache,  vertigo,  transient  deafness  or  blindness, 
sensation  of  numbness  of  the  extremities,  with  local  palsies,  together 
with  the  constant  dread  of  an  attack. 

The  attack  may  begin  with  vomiting,  followed  by  either  partial 
or  complete  insensibility,  or  suddenly,  the  patient  becoming  at 
once  unconscious  and,  if  standing  at  the  time,  sinking  to  the  ground 
completely  relaxed  or,  rarely,  with  spasmodic  or  convulsive  move- 
ments. Respiration  is  slow,  irregular,  and  noisy;  during  inspiration 
the  paralyzed  cheek  is  drawn  in;  and  during  expiration  puffed  out. 
The  pulse  is  slow  and  full  and  there  is  throbbing  of  the  carotids.  The 
face  is  flushed,  the  eyes  congested,  and  the  pupils  are  uninfluenced 
by  light.  The  temperature  falls  a  degree  or  two  below  normal  but 
rises  within  twenty-four  hours  to  ioo°  to  ioi°F.  In  fatal  cases  the 
temperature  may  rapidly  rise  to  io6°  to  io8°F. 

The  muscular  system  is  profoundly  relaxed;  the  reflex  movements 
are  abolished,  but  return  with  consciousness.  Babinski's  sign  is 
present.  Involuntary  urination  and  defecation  are  frequent.  The 
head  and  eyes  deviate  in  many  cases  toward  the  affected  side  in  the 
brain  or  from  the  paralyzed  side;  they  "look  toward  the  lesion." 
Convulsions  rarely  occur. 

Ingravescent  apoplexy  begins  as  a  mild  stroke  with  a  rapid  return 
to  consciousness  and  power,  except,  perhaps,  of  speech.  Headache 
is  present  with  some  one  or  more  local  symptoms,  and  in  a  few  hours 
to  a  few  days  consciousness  gradually  becomes  impaired,  the  loss 
of  power  again  occurs,  and  the  coma  deepens,  the  patient  dying 
comatose. 

If  the  unconsciousness  continues  longer  than  twenty-four  hours, 
death  is  the  usual  termination,  preceded  by  pale  face,  irregular  and 
rapid  pulse  and  respiration,  and  rise  of  temperature. 

Reaction  takes  place  in  many  cases  in  from  one-half  to  three  hours, 
consciousness  gradually  returning  and  reflex  excitability  slowly 
reviving.  It  is  associated  with  headache,  confusion  of  mind,  and 
more  or  less  paralysis  of  motion  and  sensation  on  one  side  of  the 
body  {hemiplegia).  The  electro-excitability  of  the  paralyzed  parts 
is  preserved.  Irritation  of  the  motor  fibers  shortly  induces  contrac- 
tion of  the  affected  muscles  (primary  rigidity).  Contractions 
later  in  the  course  of  the  affection  are  of  unfavorable  significance 
as    they    indicate    degeneration    in    the   motor    tracts    (secondary 


CEREBRAL   HEMORRHAGE  549 

rigidity).  Recovery  from  the  attack  may  be  delayed  by  inflamma- 
tory symptoms,  the  temperature  rising  to  101°  to  io4°F.,  and  by 
severe  neuralgic  pains  and  the  muscle  contractions. 

Localization  of  the  lesion  of  a  cerebral  hemorrhage  is  of  great 
practical  importance. 

Capsular  hemorrhage,  or  hemorrhage  into  the  internal  capsule  at 
the  anterior  portion  around  the  genu  (knee),  where  the  motor  fibers 
pass  and  converge,  coming  from  the  hemispheres,  is  frequent,  causing 
loss  of  consciousness  of  sudden  or  rapid  onset,  hemiplegia,  involving 
face,  arm,  and  leg,  with  motor  aphasia  if  the  hemiplegia  be  on  the 
right  side.  There  is  also  a  unilateral  loss  of  reflex  action,  conjugate 
deviation  of  the  eyes  from  the  paralyzed  side,  and  unilateral  de- 
fective movement  with  flaccidity  of  the  limbs. 

Cortical  hemorrhage  gives  rise  to  localized  unilateral  paralysis  of 
the  face,  the  arm,  or  the  leg,  with  local  convulsions  or  convulsions 
that  have  a  local  beginning,  or  profound  unconsciousness. 

Centrum  ovale  hemorrhages  resemble  the  cortical  as  regards  the 
local  convulsions. 

Crus-cerebri  hemorrhage  produces  loss  of  consciousness  with  hemi- 
plegia involving  the  lower  half  of  the  face  and  the  limbs,  with  paralysis 
of  the  third  nerve  on  the  opposite  side,  or  the  side  of  the  lesion.  The 
unilateral  third  nerve  symptoms  are  ptosis,  external  strabismus, 
dilatation  of  the  pupil,  and  loss  of  accommodation  for  near  objects. 
The  paralysis  is  termed  "crossed"  or  "alternate''  hemiplegia. 

Pons  hemorrhage  causes  either  general  convulsions  or  irregular 
convulsions  in  the  legs,  bilateral  motor  paralysis,  bilateral  anesthesia, 
contracted  pupils,  embarrassed  respiration,  repeated  vomiting 
without  nausea,  and  high  temperature.  If  the  hemorrhage  is  large, 
death  is  sudden  or  within  a  few  hours,  and  even  if  small,  the  prognosis 
is  unfavorable. 

Ventricular  hemorrhages  are  generally  of  the  ingravescent  variety, 
and  are  characterized  by  a  second  apoplectic  seizure  soon  after  the 
first,  with  extension  of  the  hemiplegic  symptoms,  or  a  relaxation  of 
the  muscles,  from  one  side  to  both  sides  of  the  body. 

Cerebellar  hemorrhages  vary  so  greatly  in  the  symptoms  that  a 
positive   diagnosis   can  seldom  be  made. 

Meningeal  or  dural  hemorrhage  is  usually  due  to  a  trauma.  Two 
varieties:  I,  Infantile  meningeal  hemorrhage,  occurring  during  labor. 
II.  Extradural  hemorrhage,  the  result  of  direct  injury  to  the  head. 

The  infantile  variety  presents  symptoms  of  irritation  and  com- 


550  CEREBRAL   HEMORRHAGE 

pression  of  the  cortex,  such  as  convulsions,  general  or  unilateral; 
rigidity,  opisthotonos,  and  either  hemiplegia  or  diplegia. 

The  extradural  variety  is  almost  always  the  result  of  fracture  or 
trauma  of  the  skull,  resulting  in  an  extravasation  of  blood  between 
the  dura  and  the  skull,  from  the  middle  meningeal  artery ;  the  hemor- 
rhage may  be  on  one  or  both  sides.  The  symptoms  may  develop 
at  once  or  after  some  days,  and  are  those  of  pressure;  hemiplegia, 
partial  or  complete;  convulsions,  impaired  or  absent  reflexes,  dilata- 
tion with  loss  of  reaction  of  pupil  of  opposite  side;  and  stupor, 
gradually  deepening  into   coma  and   death. 

Sequelae. — Paralysis  of  the  muscles  of  the  face,  tongue,  body,  and 
extremities  of  one  side,  opposite  to  the  location  of  the  hemorrhage, 
termed  unilateral  paralysis,  or  right  or  left  hemiplegia. 

Paralysis  of  both  sides  of  the  body,  due  to  simultaneous  hemor- 
rhage on  both  sides,  termed  bilateral  hemiplegia,  or  diplegia. 

Paralysis  of  one  side  of  the  face  and  of  the  extremities  of  the 
opposite  side,  due  to  hemorrhage  into  the  pons  Varolii,  termed 
alternating  or  crossed  paralysis. 

Occasionally  tonic  contractions  occur  in  muscles  long  paralyzed, 
termed  late  rigidity,  and  constitute  evidence  of  a  secondary  degenera- 
tion of  the  nerve  fibers. 

Choreic  movements  in  paralyzed  muscles  are  termed  post-hemi- 
plegic  chorea,  due,  according  to  Charcot,  to  changes  in  the  motor 
centers.  i 

The  mental  powers  are  always  more  or  less  permanently  impaired, 
the  patient  irritable  and  emotional,  with  loss  of  memory  in  varying 
degrees. 

Diagnosis. — The  diagnosis  of  the  apoplectic  seizure  is  often  one 
of  the  most  difficult  questions  in  medicine,  and  yet  of  the  greatest 
importance,  as  the  treatment  depends  upon  its  accuracy.  The 
diagnosis  of  the  sequelas  is  comparatively  easy. 

Alcoholic  insensibility  differs  from  apoplexy  in  the  following  points: 
insensibility  is  not  so  complete,  no  drawing  in  and  puffing  out  of 
one  cheek  with  respiration,  the  pulse  frequent  instead  of  slow,  the 
pupils  influenced  by  light;  upon  raising  both  legs,  no  difference  is 
apparent  in  allowing  them  to  drop;  the  eyes  and  head  are  not  turned 
to  one  side,  and,  lastly,  the  condition  is  ameliorated  on  the  inhalation 
of  ammonia.  Von  Wedekind's  test  is  generally  satisfactory:  "By 
simply  pressing  on  the  supraorbital  notches  with  a  steadily  increas- 
ing force  one  may,  with  certainty  of  success,  bring  an  unconscious 


CEREBRAL  HEMORRHAGE  551 

alcoholic  to  his  senses,  and  thus  differentiate  between  alcoholic 
and  other  comas." 

Opium  poisoning  differs  from  apoplexy  by  the  gradual  approach 
of  the  coma,  the  contracted  pupil,  slow  pulse,  and  quiet,  slow  respira- 
tion; the  patient  can  be  momentarily  aroused,  and  the  heavy  stertor 
of  apoplexy  is  absent. 

Uremia  causes  a  coma  that  closely  resembles  apoplexy.  A  history 
of  Bright's  disease  and  the  presence  of  albuminuria  at  once  clear  up 
the  case;  again,  uremic  coma  is  generally  preceded  by  convulsions; 
a  rapid  rise  of  temperature  is  present  as  shown  by  the  thermometer, 
often  104°  to  io6°F.,  while  to  the  hand  the  surface  appears  but  little, 
if  at  all,  above  the  normal;  the  pulse  is  usually  weak  with  irregular 
force,  the  respirations  averaging  25  to  30  per  minute,  and  the  face 
having  a  glossy  appearance. 

Cerebral  embolism  cannot  always  be  differentiated  from  apoplexy. 
We  may  suspect  cerebral  plugging  if  the  patient  be  young;  if  he  be 
laboring  under  acute  or  chronic  cardiac  valvular  trouble;  if,  within 
brief  periods,  several  incomplete  attacks  have  occurred  before  a 
complete  comatose  condition  obtains;  or,  if  hemiplegia  results  with 
passing  or  slight  unconsciousness;  or,  if  the  phenomena  are  sooner 
or  later  followed  by  cerebral  softening,  since  embolism  and  thrombo- 
sis are  the  most  common  causes  of  softening. 

Syncope  or  fainting  is  of  sudden  onset,  but  being  due  to  a  failure 
of  the  circulation,  the  pulse  is  feeble,  the  face  pale,  the  respirations 
quiet,  and  the  duration  of  unconsciousness  short,  all  the  very  opposite 
of  an  apoplectic  attack. 

Hysteria  may  resemble  apoplexy  at  times  but  the  history,  sex,  and 
other  characteristics  of  hysteria  will  serve  to  make  a  distinction. 

Prognosis. — If  the  patient  survive  the  immediate  effects  of  a 
cerebral  hemorrhage,  he  is  always  in  danger  of  another  attack,  since 
the  causes  of  the  original  attack  still  remain.  Another  attack  or 
two  is  the  usual  course,  a  fatal  termination  ultimately  occurring. 
If  the  attack  be  due  to  or  associated  with  Bright's  disease,  recovery 
is  rare.  The  hemiplegia  is  uncertain;  a  partial  recovery  may  occur 
within  a  few  months  or  it  may  continue  for  years.  The  symptoms 
to  be  looked  upon  with  alarm  include  long-continued  loss  of  con- 
sciousness, abolition  of  reflexes,  respiratory  disturbances,  disorders 
of  .the  cardiac  function,  etc. 

Treatment. — If  there  are  prodromal  indications,  the  most  prompt 
means  of  reducing  the  intracranial  blood-pressure  is  by  venesection. 


552  CEREBRAL   HEMORRHAGE 

followed  by  a  brisk  purgative,  which  may  be  aided  by  an  immediate 
enema. 

I^.      Magnesii  sulph 5ij  60  gtn. 

Glycerini f §j  30  c.c. 

Aquae  bull f  Siij  90  c.c. 

M.  S. — Administer  by  bowel  slowly  without  force. 

If  the  patient  is  weak,  however,  leeches  should  be  applied  to  the 
mastoid  instead,  and  potassium  bromide,  gr.  xl  to  Ix  (2.6  to  4  gm.), 
or  the  fluidextract  of  ergot,  f5ss  to  j  (2  to  4  c.c),  should  be 
administered. 

During  the  attack,  the  clothing  should  be  loosened  and  all  con- 
strictions removed.  The  patient  should  be  placed  in  a  perfectly 
quiet,  cool  room;  he  should  be  promptly  placed  in  a  horizontal 
position,  with  the  head  somewhat  raised.  The  face  should  be  a  little 
downward,  so  that  the  tongue,  palate,  and  secretions  may  fall  for- 
ward instead  of  backward  into  the  pharynx.  An  ice-bag  should  be 
applied  to  the  head,  and  a  hot  mustard  foot-bath  should  be  employed. 
Venesection  should  be  performed  at  once  as  it  aids  in  lessening  the 
cerebral  congestion.  Prompt  catharsis  by  means  of  croton  oil, 
TTlij  (0.12  c.c),  with  glycerin,  TIlxv  (i.  c.c),  placed  on  the  back  of  the 
tongue,  is  also  advisable;  or  gr.  3^  (0.016  gm.),  of  elaterium,  dissolved 
in  a  little  water,  may  be  given  in  the  same  way.  If  the  pulse  is  full 
and  strong  after  consciousness  is  regained,  either  tincture  of  vera- 
trum  viride  or  tincture  of  aconite  is  indicated.  If,  during  the  attack, 
the  face  becomes  pallid,  and  the  pulse  irregular,  and  the  patient  is 
prostrated  with  shock,  diffusible  stimulants  such  as  ammonia  and 
ether,  cautiously  employed,  will  be  of  great  value. 

For  the  secondary  fever,  tincture  of  aconite  or  tincture  of  vera- 
trum  viride  may  be  used,  and  for  the  headache  and  delirium  camphor 
and  bromides  may  be  employed.  Absorption  of  the  clot  may  be 
hastened  to  some  extent  by  keeping  the  secretions  active  and  by  the 
administration  of  potassium  iodide  or  bichloride  of  mercury  alternat- 
ing with: 

I^.     Liq.  potassii  arsenit Tllv  0.3  c.c. 

Syr.  calcii  lacto-phosph. .  .  .   f  5ij  8.0  c.c. 

M.  S. — Three  times  a  day. 

Subsequent  to  the  attack  the  patient  should  be  placed  on  a  liquid 
or  semisolid  diet.  Absolute  cleanliness  in  the  care  of  the  patient  is 
highly  essential  in  order  to  prevent  the  formation  of  bedsores.     The 


CEREBRAL    THROMBOSIS   AND   EMBOLISM  553 

bowels  should  be  moved  daily  and  the  quantity  of  urinary  secretion 
should  be  carefully  watched.  Bathing  with  alcohol  serves  to  render 
bhe  patient  very  comfortable.  Frequently  the  speech  is  lost,  either 
temporarily  or  permanently  and  in  these  cases  the  attendant  vShould 
inquire  after  the  needs  of  the  patient,  as  otherwise  he  may  be  seriously 
neglected.  After  two  or  three  months  a  weak  galvanic  current 
applied  directly  to  the  head  by  placing  an  electrode  on  each  mastoid 
process  promotes  absorption.  For  the  paralyzed  muscles,  the  faradic 
current,  applied  by  placing  one  electrode  over  or  near  the  nerve 
innervating  the  muscle  and  the  other  over  its  belly,  acts  as  a  tonic, 
preventing  wasting;  it  is  assisted  by  hypodermic  injections  into  the 
paralyzed  muscles  of  strychnine  sulphate,  gr.  3^4  (o.ooi  gm.),  four 
times  a  week.     Massage  and  warm  salt  baths  are  also  of  value. 

CEREBRAL  THROMBOSIS  AND  EMBOLISM 

Synon3mis. — Partial  cerebral  anemia;  occlusion  of  cerebral  vessels; 
cerebral  softening. 

Definition. — The  occlusion  of  a  cerebral  vessel,  from  the  formation 
of  a  thrombus  or  the  presence  of  an  embolus,  thus  causing  anemia 
of  some  portion  of  the  brain;  characterized  by  gradual — when  the 
result  of  thrombosis — and  sudden — when  due  to  embolism — develop- 
ment of  headache,  vertigo,  disorders  of  intelligence,  with  more  or 
less   complete  insensibility  and  paralysis. 

Causes. — Thrombosis,  or  the  formation  of  a  clot  in  the  vessel — 
an  ante-mortem  coagulation — is  almost  always  the  result  of  chronic 
endarteritis,  as  seen  in  the  aged,  together  with  a  slowing  and  weaken- 
ing of  the  blood  current.  Chronic  alcoholism  and  syphilis  are  the 
usual  causes  when  occurring  in  young  adults. 

Emboli,  in  the  great  majority  of  instances,  result  from  an  endo- 
carditis— cardiac  emboli;  small  particles  of  the  exudation  being 
carried  into  the  circulation  and  deposited  in  the  brain.  Emboli  may 
also  be  derived  from  an  aortic  aneurysm  or  syphiloma  of  the  great 
vessels. 

Pathological  Anatomy. — The  cerebral  arteries  may  be  obstructed 
by  emboli  or  thrombi;  the  cerebral  veins  and  sinuses  by  thrombi  only. 
The  changes  in  the  cerebral  tissue  are  those  of  anemia  of  the  part  or 
parts  supplied  by  the  occluded  vessels.  The  subsequent  changes 
depend  upon  the  anatomy  of  the  vessels.  If  the  obstructed  artery 
has  anastomoses,  the  collateral  circulation  is  soon  established  and 


554  CEREBRAL   THROMBOSIS   AND  EMBOLISM 

the  brain-tissue  assumes  its  normal  condition.  If,  on  the  other 
hand,  the  occluded  vessel  be  one  of  "Cohnheim's  terminal  arteries" 
— arteries  without  anastomoses,  such  as  the  lenticular-optic  and  the 
lenticulo -striate  set  of  arteries,  branches  of  the  Sylvian  artery — 
the  blood  in  the  whole  extent  of  the  occluded  vessels  coagulates. 

As  a  result  of  the  anatomical  arrangement,  collateral  circulation 
is  never  established  and  the  anemic  structure  supplied  by  the  affected 
vessel  dies  or  undergoes  necrobiosis  followed  by  yellowish-white 
softening.  If  the  vessel  beyond  the  seat  of  the  occlusion  remains 
pervious,  blood  flows  back  through  the  capillaries  from  the  nearest 
artery  or  vein,  the  parts  that  a  short  time  before  were  bloodless  now 
become  deeply  engorged,  the  succeeding  changes  in  the  vessels 
permitting  diapedesis  of  the  red  blood  corpuscles.  The  tissues  which 
are  undergoing  disintegration  are  colored  by  the  red  corpuscles, 
causing  the  appearance  known  as  ''red  softening,"  which  after  some 
weeks  becomes  "yellow  softening,"  finally  changing  to  "white  soften- 
ing," when  there  is  a  milky,  or  rather  creamy  fluid  mixed  with  masses 
or  particles  of  broken-down  nerve  elements.  Infective  emboli  may 
produce  abscesses  in  the  brain. 

The  vessel  most  commonly  occluded  is  the  left  middle  cerebral 
artery,  which  sends  branches  to  the  second  and  third  frontal  convolu- 
tions, the  anterior  and  superior  portions  of  the  three  temporal 
convolutions,  the  island  of  Reil,  the  parietal  convolutions,  part  of 
the  external  and  all  of  the  internal  capsule,  the  lenticular  nucleus, 
and  most  of  the  corpus  striatum  (the  motor  centers  are  therefore 
included) . 

Symptoms. — Thrombosis  is  characterized  by  a  gradual  onset. 
It  is  most  common  in  the  aged  and  is  manifested  by  persistent  head- 
ache and  vertigo  of  varying  intensity;  alterations  in  the  character, 
the  patient  becoming  irritable,  morose,  and  despondent  with  periods 
of  absent-mindedness;  disorders  of  vision,  impairment  of  memory; 
hesitating  and  mumbling  speech ;  impaired  locomotion  with  muscular 
weakness  and  trembling;  and  finally  paralysis.  Hemiplegia  is 
common  and  ijiay  appear  gradually  or  be  preceded  by  sudden 
insensibility;  the  condition  progresses  and  ends  in  dementia  and 
finally  death  from  exhaustion.  Rarely,  a  collateral  circulation  is 
established  and  partial  or  complete  recovery  occurs. 

In  cerebral  embolism,  the  symptoms  occur  suddenly  and  may  be 
mild  or  grave  in  character. 

In  the  mild  variety,  there  are  sudden  and  severe  vertigo,  confusion 


CEREBRAL   THROMBOSIS   AND   EMBOLISM  555 

of  mind,  muscular  twitchings,  usually  one-sided,  and  vomiting, 
followed  by  hemiplegia,  most  frequently  of  the  right  side,  the  intel- 
lect remaining  clear  but  hesitating.  After  some  weeks  or  months 
the  paralysis  usually  disappears  and  recovery  is  complete. 

The  grave  or  apoplectic  variety  is  manifested  by  sudden  headache, 
vertigo,  flushing  or  pallor  of  the  face,  sudden  unconsciousness,  often 
preceded  by  a  sharp  cry,  and  complete  muscular  relaxation  followed 
by  death,  or  a  gradual  return  to  consciousness  with  hemiplegia, 
usually  right-sided,  and  aphasia.  The  loss  of  speech  may  last  several 
weeks  or  months  or  may  be  persistent.  The  mind  may  remain 
normal  or  may  be  greatly  enfeebled,  the  reason  and  judgment  be 
clouded,  and  after  a  varying  period  dementia  develops,  being  followed 
by  exhaustion  and  death. 

The  following  localizing  signs  will  serve  to  determine  the  situation 
of  the  obstruction: 

Vertebral  artery,  the  left  most  frequently,  when  obstructed  results 
in  acute  bulbar  paralysis  from  involvement  of  the  nuclei  in  the 
medulla,  with  or  without  hemiplegia. 

Basilar  artery  obstruction  causes  diplegia  with  bulbar  symptoms. 
There  is  rapid  rise  of  temperature.  Death  follows  within  a  day  or 
two,  or  suddenly,  if  the  respiratory  centers  are  involved. 

Middle  cerebral  artery  or  one  of  its  branches  is  the  most  frequent 
seat  of  embolic  or  thrombotic  occlusions.  The  symptoms  depend 
upon  the  exact  branch  involved;  if  plugged  before  the  central  arteries 
are  given  off,  the  internal  capsule  is  deprived  of  its  blood-supply 
and  permanent  hemiplegia  may  follow;  if  the  blocking  is  in  the 
central  branches,  the  hemiplegia  involves  the  arm  and  face,  and  if 
the  left  side,  aphasia  occurs.  The  individual  branches  passing  to  the 
third  frontal  (aphasia),  the  ascending  parietal  (hemiplegia),  supra- 
marginal  and  angular  gyri  (word  blindness),  and  the  temporal  gyri 
(word  deafness),  may  be  plugged. 

Duration. — Thrombosis  is  essentially  an  affection  of  the  elderly 
and  has  a  chronic  course.  Months  and  years  may  be  occupied  with 
the  various  symptoms  until  the  phenomena  of  secondary  dementia 
develop. 

Embolism  is  of  sudden  onset,  and  may  be  followed  by  a  rapid 
recovery. 

Diagnosis. — Caille  gives  the  following  differential  diagnosis: 

^'Cerebral  hemorrhage  occurs  after  the  age  of  fifty-five,  as  a  rule, 
with  atheromatous  arteries  and  an  hypertrophied  heart.     The  onset 


556  CEREBRAL   THROMBOSIS   AND   EMBOLISM 

is  sudden,  with  coma,  during  exertion  or  excitement.  The  tempera- 
ture falls  in  an  hour,  and  then  rises,  sometimes  to  io6°F.  Gradual 
recovery  of  consciousness  takes  place  in  from  three  to  five  days,  with 
permanent  hemiplegia. 

"Cerebral  embolism  comes  at  any  age,  with  heart  disease  or  after 
childbirth.  There  is  a  sudden  onset,  without  loss  of  consciousness 
or  with  slight  mental  confusion,  or  with  rapid  return  to  consciousness. 
The  temperature  does  not  fall,  but  may  rise  as  high  as  io2°F.  Im- 
provement occurs  within  twenty-four  hours  to  a  marked  degree,  but 
after  three  or  four  days  the  symptoms  return.  Monoplegia,  hemi- 
plegia, or  aphasia  may  remain.  Jacksonian  epilepsy  may  develop 
if  the  lesion  is  cortical,  involving  a  special  center. 

"Cerebral  thrombosis  occurs  at  any  age,  but  chiefly  in  syphilitic 
persons  and  middle-aged  men.  There  are  usually  premonitions. 
The  onset  is  slower,  without  coma,  but  with  dullness  of  the  mind. 
The  temperature  does  not  fall,  but  may  rise  to  ioo°F.  The  paralysis 
is  similar  to  that  observed  in  embolism. 

"The  diagnosis  between  these  three  conditions  is  hardly  ever 
positive." 

Prognosis. — Thrombosis  is  a  permanent  and  progressive  condi- 
tion in  the  majority  of  instances.     Recovery  is  a  rare  termination. 

Embolism  may  be  followed  by  a  perfect  recovery.  Usually,  how- 
ever, some  evidences  of  the  plugging  remain  permanently.  Death 
may  be  the  result  within  a  day  or  two,  from  the  plugging  of  a  large 
vessel,  the  patient  never  emerging  from  the  coma.  In  other  cases 
the  patient  arouses  from  the  coma,  the  hemiplegia  with  aphasia 
persisting,  and  the  case  pursues  the  usual  course  of  localized  cerebral 
softening. 

Treatment. — Blood-letting  is  contraindicated.  The  indication  in 
the  early  stage  of  embolism  and  thrombosis  is  to  reestablish  the 
circulation  within  the  area  deprived  of  its  blood-supply,  in  order  to 
prevent  the  changes  incident  to  defective  nutrition;  this  is  accom- 
plished by  measures  to  strengthen  the  heart's  action,  tonics,  perfect 
rest  for  some  time  after  the  attack,  a  plain  but  nutritious  diet,  and 
attention  to  the  various  secretions.  Bartholow  advises  the  adminis- 
tration of  ammonium  carbonate,  gr.  x  (0.6  gm.),  and  ammonium 
iodide,  gr.  v  (0.3  gm.),  three  times  daily  over  a  long  period,-  the 
objects  being  to  increase  the  action  of  the  heart  and  arteries,  and  to 
effect  a  solution  of  the  thrombus  by  maintaining  the  alkalinity  of 
the  blood.     Rest  in  bed  with  the  head  elevated  should  never  be 


CEREBRAL   ABSCESS  557 

neglected  in  these  cases.  In  cases  in  which  syphiHs  is  a  factor, 
potassium  or  sodium  iodide  and  mercury  should  be  given.  Stimulants 
in  moderate  doses  are  of  value. 

In  the  aged,  presenting  indications  of  degeneration,  much  benefit 
results  from  the  use  of: 

I^.     Liquor,  potassii  arsenitis.  .  .   TTtiij  0.2  c.c. 

Syr.  calcii  lacto-phosphat . .   f5ij  8.0  c.c. 

M.  S. — After  meals,  well  diluted. 

It  may  be  combined  with  cod-liver  oil  with  decided  advantage. 
For  embolism,  the  immediate  and  persistent  use  of  the  following 
may  dissolve  the  plug: 

I^.     Ammonii  carbonat gr.  v  0.3  gm. 

Liquor,  ammonii  acetatis.  .   f  5j  4-0  c.c. 

M.  S. — Three  or  four  times  daily,  well  diluted. 

CEREBRAL  ABSCESS 

S3aionyins. — Acute  encephalitis;  suppurative  encephalitis. 

Definition. — An  acute  suppurative  inflammation  of  the  brain 
structure,  either  localized  or  diffused,  primary  or  secondary;  charac- 
terized by  impairment  of  intellect,  sensation,  and  motion. 

Causes. — Primary  cerebral  abscess  is  exceedingly  rare,  and  is  due 
to  pyemia,  glanders,  and  embolus  from  ulcerative  endocarditis. 

Secondary  cerebral  abscesses  result  from  injuries  to  the  cerebral 
tissues,  following  apoplexy,  embolism,  thrombosis,  and  injuries  to 
the  cranial  bones,  chronic  suppurative  otitis,  and  chronic  suppuration 
in  some  other  portion  of  the  body. 

Pathological  Anatomy. — Abscesses  of  the  brain  may  be  single  or 
multiple,  varying  in  size  from  an  almond  to  an  egg. 

They  occupy  a  limited  and  well-defined  region  of  the  cerebral 
tissue,  such  as  either  the  corpora  striata,  optic  thalami,  gray  matter 
of  the  cortex,  the  cerebellum,  or  the  white  matter  of  the  hemispheres. 
Cerebral  abscesses  are  usually  due  to  microorganisms  and  are  more 
frequent  in  the  right  hemisphere  than  the  left.  When  the  result 
of  pyemia  or  infection  from  distant  organs,  such  as  the  lungs,  they 
are  generally  multiple.  When  secondary  to  disease  of  the  ear,  frontal 
sinuses,  naso-pharynx,  or  trauma,  they  are  usually  single. 

An  abscess  having  developed,  steadily  increases  in  size,  encroach- 
ing upon  the  surrounding  brain,  and  usually  the  brain  tissue  forms  a 


558  CEREBRAL  ABSCESS 

defensive  wall  about  the  abscess — a  capsule  or  pyogenic  membrane. 
The  encapsulated  abscess  continues  to  develop,  and  finally  bursting, 
infiltrates  the  surrounding  tissue  with  consequent  pressure,  or  dis- 
charges into  the  meshes  of  the  pia-arachnoid,  on  the  cortex,  or  into 
the  lateral  ventricles.  Rarely,  an  encapsulated  abscess  may  become 
permanently  encysted.  The  pus  of  cerebral  abscess  is  greenish  or 
greenish-yellow  in  color,  and  fetid  (Dercum). 

Symptoms. — A  concise  description  of  the  symptoms  of  abscess 
of  the  brain  is  very  difficult,  on  account  of  the  wide  variations 
dependent  on  its  location,  and  also  the  difficulty  of  isolating  it  from 
the  affections  to  which  it  is  secondary. 

The  onset  varies  according  to  the  cause,  although  all  cases  are 
associated  with  headache,  irritative  fever,  vomiting,  persistent  and 
spreading  paralysis,  convulsions,  optic  neuritis,  mental  apathy, 
delirium,  and  coma. 

If  consecutive  to  apoplexy,  thrombosis,  or  emboli,  there  occur- 
fever  and  delirium,  the  paralysis  remaining  and  spreading  with 
spasmodic  contractions  of  the  affected  muscles. 

If  secondary  to  a  chronic  ear  disease,  there  is  sudden  cessation  of 
the  ear  discharge;  severe  pain  in  ear  and  side  of  head,  accompanied 
with  chill,  fever,  vomiting,  followed  in  a  few  days  by  the  disappear- 
ance of  febrile  symptoms  and  the  development  of  a  condition  of 
stupor,  with  cerebral  symptoms,  depending  upon  the  location  of  the 
abscess. 

Occasionally,  cases  run  a  chronic  course  with  rather  insidious  onset, 
dull,  persistent  headache;  changed  disposition,  peevish,  irritable, 
unreliable,  with  decline  of  moral  sensibility;  easily  fatigued  by  mental 
work;  inability  to  stand  exertion;  impaired  memory;  vertigo;  and 
dyspepsia;  soon  followed  by  slight  palsies,  which  progressively  in- 
crease, becoming  general,  with  involuntary  discharges,  death  follow- 
ing from  exhaustion. 

Of  the  focal  symptoms,  hemiplegia,  of  incomplete  character,  occurs 
in  about  one-half  of  all  cases  of  abscess  of  the  brain.  A  very  constant 
symptom  of  diagnostic  value,  when  hemiplegia  is  very  marked,  is 
exaggerated   knee-jerk   with   pronounced   ankle   clonus. 

Diagnosis. — A  positive  diagnosis  is  only  possible  by  a  close  study 
of  the  causes  and  the  clinical  history,  as  the  symptoms  at  times 
indicate  meningitis  and  again  cerebral  tumor. 

Purulent  meningitis  may  follow  trauma  to  the  brain  or  chronic 
ear  disease,  making  the  diagnosis  impossible.     The  chief  points  of 


CEREBRAL    TUMOR  559 

distinction  are:  The  subacute  or  chronic  course  of  abscess,  slight 
involvement  of  cranial  nerves,  hemiplegia,  and  the  presence  of  an 
active,  persistent,  unilateral  ankle  clonus  and  exaggerated  knee- 
jerk  on  paralyzed  vSide. 

Prognosis. — The  usual  termination  is  in  death.  The  course 
depends  upon  the  character  and  extent  of  the  injury,  varying  from  a 
few  days  to  several  months. 

Treatment. — Surgical  treatment  has  been  attended  with  marked 
success  in  some  cases  of  abscess  of  the  brain,  the  withdrawal  of  the 
pus  being  followed  by  recovery.  For  traumatic  abscess  the  operation 
of  trephining  is  indicated.  When  operation  is  for  any  reason  im- 
practicable, the  treatment  is  purely  symptomatic. 

CEREBRAL  TUMOR 

Synonjrm. — Intracranial  tumor. 

Definition. — Tumor  of  the  brain  is  either  a  growth  in  the  cerebral 
tissue,  on  the  meninges,  or  in  the  vessels,,  and  is  characterized  by 
symptoms  of  pressure  upon  the  brain  structure. 

Causes. — The  most  important  etiological  factors  are  male  sex, 
middle  age,  heredity,  injuries  to  the  head,  vascular  changes,  syphilis, 
tuberculosis,  and  cancer. 

Pathology. — Tumors  of  the  brain  are  of  various  kinds,  viz.,  vascular 
tumors,  aneurysms;  parasitic  tumors,  cysticercus;  diathetic  tumors, 
tubercle  or  syphilis;  accidental  tumors,  glioma.  The  most  common 
cerebral  growths  are  tubercle,  gumma,  glioma,  sarcoma,  carcinoma, 
and  cysts.  The  size  of  the  tumors  varies  and  they  may  attain  the 
size  of  an  orange  before  they  induce  symptoms.  All  growths  of  the 
brain  produce  irritation  of  the  surrounding  parts  at  first,  and  later 
by  pressure  give  rise  to  interference  with  the  blood-supply  and 
destruction  of  the  tissues. 

Symptoms. — Those  common  to  all  cerebral  tumors  are:  Headache, 
persistent  and  increasing  in  intensity;  defects  of  vision,  even  blind- 
ness, due  to  an  optic  neuritis,  a  very  constant  symptom;  defects  of 
hearing,  taste,  and  of  speech,  the  result  of  paresis  of  the  vocal  cords; 
vertigo,  associated  with  nausea  and  vomiting  and  convulsions, 
epileptiform  in  character.  These  convulsions  are  usually  limited  to 
one  side  of  the  body  and  occur  at  regular  intervals.  They  may  be 
localized  (Jacksonian  epilepsy)  to  one  or  more  groups  of  muscles  and 
are  never  attended  with  loss  of  consciousness.     Nystagmus  is  some- 


560  CEREBRAL   TUMOR 

times  present.  Palsies  such  as  strabismus,  ptosis,  dilatation  of  the 
pupil,  facial  palsy,  paraplegia,  and  hemiplegia  are  not  uncommon 
symptoms.  Defects  of  sensibility  such  as  sensations  of  numbness 
and  coldness  in  the  limbs  and  body  may  also  occur.  Occasionally, 
there  are  disturbances  of  equilibrium,  manifested  by  a  tendency, 
when  standing,  to  go  backward  or  turn  to  the  right  or  left.  The 
intellectual  faculties  may  be  well  preserved  until  late  in  the  affection 
when  irritability  of  temper,  depression  of  spirits,  impairment  of 
memory,  emotional  disturbances,  and  a  gradually  advancing  dementia 
may  develop.  Slowing  of  the  pulse,  insomnia,  and  increased  secretion 
of  urine  sometimes  accompany  cerebral  tumors. 

Diagnosis. — A  positive  diagnosis  can  rarely  be  made.  The  fol- 
lowing points  will  aid:  Long-continued  persistent  headache,  without 
appreciable  cause;  unilateral  epileptiform  convulsions,  without  loss 
of  consciousness;  difficulty  of  vision,  hearing,  and  speech,  associated 
with  nausea  and  vomiting,  and  local  and  general  palsies. 

The  location  of  the  tumor  may  be  determined  by  the  more  or  less 
pronounced  character  of  certain  symptoms. 

The  diagnosis  of  the  character  of  the  growth  can  only  be  deter-, 
mined  by  a  close  study  of  the  history. 

According  to  Herter,  the  indications  which  suggest  that  the  tumor 
is  a  syphilitic  growth  are  as  follows:  Syphilitic  history;  symptoms  of 
irritative  disease  of  cortex  rather  than  destructive  evidences  of  rapid 
growth  at  the  onset,  followed  by  a  period  of  slow  progress  or  station- 
ary symptoms;  gradual  improvement  under  antisyphilitic  treatment; 
development  between  twenty  and  forty-five  years  of  age. 

Indications  suggesting  tuberculous  growth  are:  Family  history,  or 
tuberculosis  in  some  other  organ  of  the  patient;  rapid  development 
of  symptoms;  indications  of  the  growth  in  the  cerebellum  or  in  the 
pons;  early  appearance  of  the  symptoms,  especially  before  the  tenth 
year,  and  history  of  injury  to  head. 

Indications  suggesting  sarcoma  or  cancer  are:  The  presence  of  a 
sarcoma  elsewhere  and  rapidly  failing  health,  with  cerebral  tumor 
symptoms  in  patient  over  fifty  years. 

Indications  suggesting  glioma:  Sudden  loss  of  consciousness  with 
exacerbation  of  all  symptoms  in  the  clinical  history  of  cerebral  tumor; 
cortex  irritative  symptoms  as  in  syphiloma,  developing  under  fifty 
years  of  age,  and  the  absence  of  all  evidences  of  tubercle,  syphilis, 
sarcoma,  and  cancer. 

The  focal  symptoms  of  intracranial  tumors  are  so  important  in 


CEREBRAL   TUMOR 


561 


diagnosis  that  the  following  summary  of  symptoms  caUvSed  by  brain 
tumors  is  given: 

Prefrontal  region.  If  on  the  right  side,  there  may  be  no  symptoms 
at  all;  mental  impairment;  pressure  in  central  region,  causing  aphasia; 
Jacksonian  epilepsy,  and  disturbances  of  smell. 

Central  region.  Motor  aphasia,  monoplegia,  partial  anesthesia, 
Jacksonian  epilepsy. 

Posterior  parietal  region.  Word-blindness,  homonymous  hemi- 
anopsia, disturbed  muscular  sense. 

Corpus  callosum.     Progressive  hemiplegia. 

Internal  capsule.  Hemiplegia  and  hemianesthesia,  of  opposite 
side  of  body. 

Crus  cerebri.     Crossed  paralyses  of  oculomotor  nerve  and  limbs. 

Corpora  quadrigemina.  Oculomotor  paralyses,  reeling  gait,  pos- 
sibly blindness  and  deafness. 

Pons  and  medulla.  Crossed  paralysis  of  face  and  limbs,  or  tongue 
and  limbs.     Other  lesions  in  cranial  nerves. 

Cerebellum.  Marked  cerebellar  ataxia,  vomiting,  convulsions, 
coma. 

Base,  anterior  fossa.  Mental  enfeeblement,  disturbances  of  smell 
and  vision,  and  exophthalmos. 

Base,  middle  fossa.  Impairment  of  vision;  hemiplegia;  oculomotor 
disturbances. 

Base,  posterior  fossa.  Trigeminal  neuralgia;  neuro-paralytic  oph- 
thalmia; paralysis  of  the  face  and  tongue;  impaired  hearing;  crossed 
paralyses. 

Diagnosis  between  cerebral  tumor  and  abscess.  Both  may  have 
any  or  all  of  the  following  symptoms:  Headache,  vomiting,  double 
optic  neuritis,  and  mental  failure.     Tumor  has,  in  addition,  marked 


Tumor 


Abscess 


Meningitis 


History  indefinite. 


Onset  gradual 

Optic  neuritis  usually  well 

marked. 
Monoplegia,  hemiplegia,  or 

localized    convulsions,    in 

definite  order. 
Febrile  symptoms  absent. 

Duration  months  to  years; 
regular  course. 

36 


Otorrhea  or  other  suppura- 
tive condition. 

Onset  usually  abrupt 

Optic  neuritis  usually  absent 
or  late. 

Focal  symptoms  indicative  of 
cerebellum  or  temporal  lobe. 

Temperature  sometimes  sub- 
normal. 

Duration  variable  with  latent 
periods. 


Tuberculous  history  or  diath- 
esis. 
Onset  rapid. 
Optic  neuritis  rare. 

Irregular    palsies    and    con- 
vulsions. 

Temperature  irregular. 

Duration  of  weeks,  at  times 
irregular. 


562  ■  APHASIA 

focal  symptoms,  monoplegia,  hemiplegia,  paralysis  of  cranial  nerves , 
and  marked  optic  neuritis;  the  absence  of  these  favors  abscess.  If 
the  hemiplegia  is  due  to  abscess,  the  ankle  clonus  and  knee-jerk  are 
exaggerated.  Fever  and  rigors  point  to  abscess.  The  causes  of 
abscess  are  very  clear,  those  of  tumor  often  uncertain. 

The  differential  diagnosis  between  tumor,  abscess,  and  tuberculous 
meningitis  is  given  in  the  preceding  table  (Turner). 

Prognosis. — Except  in  cases  of  syphilitic  origin  the  prognosis  is 
very  unfavorable  and  even  in  syphiloma  the  termination  may  be 
fatal  if  the  treatment  is  not  prompt. 

Treatment. — -This  is  unsatisfactory  and  consists  largely  in  measures 
for  the  relief  of  the  symptoms.  As  benefit  occasionally  follows  the 
use  of  potassium  iodide,  gr.  xx  (1.3  gm.),  three  times  daily,  and  also 
fiuidextract  of  ergot,  f  5ss  to  j  (2  to  4  c.c),  three  times  a  day,  increased 
until  their  full  physiological  effects  are  produced,  these  remedies 
should  be  used  in  all  cases,  discontinuing  them  if  no  benefit  follows 
a  prolonged  trial.  When  the  evidences  of  syphilis  are  unmistakable, 
the  mercurials  should  be  given,  in  addition,  pushed  to  their  point  of 
tolerance.  When  the  tumor  can  be  localized  and  is  accessible, 
surgical  intervention  is  indicated. 

APHASIA 

Definition. — The  loss,  partial  or  complete,  of  the  power  of  ex- 
pression or  comprehension  of  language.  A  loss  of  memory  for 
words.     Aphasia  is  a  symptom  and  not  a  disease. 

Amnesic  aphasia,  or  loss  of  the  memory  of  words  by  which  ideas 
are  expressed. 

Ataxic  aphasia,  the  inability  to  combine  the  different  parts  of 
the  vocal  apparatus  for  vocal  expression,  although  the  memory  of 
words  still  remains,  so  that  the  afflicted  person  can  write  his  ideas 
intelligently. 

Agraphia,  the  inability  to  recognize  and  make  signs  by  which  ideas 
are  communicated  in  written  language. 

Paraphasia,  the  mental  state  in  which  the  wrong  words  are  used 
to  express  an  idea. 

Paragraphia,  the  state  in  which  wrong  or  meaningless  written  signs 
are  used  to  express  an  idea. 

There  are  four  centers  concerned,  two  motor,  and  two  sensory. 
The  two  motor  centers  are:     (i)  Broca's  center,  for  speech;  and  (2) 


APHASIA 


563 


that  for  writing,  in  the  posterior  part  of  the  second  left  frontal  con- 
volution. The  two  sensory  centers  are :  (3)  The  auditory  word  center, 
in  the  posterior  part  of  the  first  temporal  convolution;  and  (4)  the 
visual  word  center,  in  the  angular  gyrus.  Lesions  of  (i)  cause 
motor  aphasia;  the  patient  cannot  express  himself  in  words,  but  he 
can  understand  what  is  said  to  him.  Lesions  of  (2)  cause  agraphia. 
Lesions  of  (3)  cause  word-deafness;  the  patient  can  hear,  but  does  not 
understand  what  he  hears.  Lesions  of  (4)  cause  alexia  or  word- 
blindness;  the  patient  can  see,  but  cannot  read  print.  The  chief 
differences  between  motor  and  sensory  aphasia  are  given  in  the 
following  table  (from  Wheeler  and  Jack) : 


Sensory   aphasia    (verbal   amnesia) 


Motor  aphasia 


Word-deafness 


Word-blindness 


Patient  almost  completely 
loses  power  of  speech. 
Words  like  oaths,  "  yes," 
or  "no,"  may  be  re- 
tained. 

Understands  what  is  said 
to  him. 

Cannot  repeat  words 

Recognizes  written  words 
but  cannot  write  them. 
Cannot  copy  print  into 
writing,  though  he  may 
copy  letters  (aphasia 
and  agraphia).  Rarely 
can  write  (aphasia  with- 
out agraphia). 

Is  aware  of  his  errors — he 
can  recall  words  but  not 
utter  them. 

Mental  impairment  is  but 
slight. 


Can  still  speak,  sometimes 
with  little  aphasia,  but 
sometimes  merely  gibberish. 


Does   not   understand   what 

is  said. 

Cannot  repeat  words ._ 

May  be  some  word-blindness 

and    agraphia,    or    patient 

may    recognize    and    write 

words  freely. 


Is  unaware  of  his  errors 
of  sp.eech — auditory  word 
memory  is_  destroyed. 

Mental  impairment  is 
marked. 


Speech  little  affected. 


Understands  what  is  said. 

Can  repeat  words. 

Cannot  recognize  written  or 
printed  words,  or  write 
them  _  (agraphia).  May 
recognize  letters,  or  his  own 
name.  If  the  damage  is 
partial,  may  write  wrong 
words  or  in  wrong  order 
{paragraphia) . 

Is  unaware  of  his  errors  in 
writing  visual  word  memory 
is  destroyed. 

Mental  impairment  is 
slight. 


Pathological  Anatomy. — Aphasia  is  not  the  result  of  any  one 
specific  lesion,  but  occurs  during  the  course  of  several,  viz.,  Occlusion 
of  certain  cerebral  vessels;  cerebral  hemorrhage;  cerebral  abscess 
or  softening;  meningitis;  tumors;  mental  or  moral  causes;  hysteria. 

It  is  now  almost  definitely  determined  that  lesions  of  the  left 
middle  cerebral  artery,  island  of  Reil,  third  frontal  convolution,  and 
parts  of  the  corpus  striatum  are  associated  in  the  production  of 
aphasia.  The  lesions  are  usually  upon  the  left  side  of  the  brain, 
the  aphasia  being  often  associated  with  right  hemiplegia. 

Symptoms. — The  degree  to  which  articul'ate  language  is  impaired 
varies  from  the  loss  of  a  few  words  to  complete  inability  to  com- 


564  "  VERTIGO 

municate  ideas.  The  intellect  does  not  suffer  in  proportion  to  the 
loss  of  words;  for,  showing  the  individual  an  article,  while  he  may 
miscall  it,  if  it  is  called  by  name  he  will  recognize  it.  This  inability 
to  convey  thoughts  is  a  source  of  great  mental  suffering,  in  some 

leading  to  a  suicidal  tendency. 

A  strange  clinical  fact  is  the  strong  tendency  to  profanity  shown 
by  aphasic  patients. 

Diagnosis. — Aphonia,  or  loss  of  voice,  should  not  be  confounded 
with  aphasia,  or  the  inability  to  remember  words. 

Paralysis  of  the  tongue,  or  inability  to  move  this  organ,  thereby 
interfering  with  articulate  language,  should  not  be  confounded  with 
aphasia,  which,  as  a  rule,  is  not  associated  with  paralysis  of  the 
tongue. 

Prognosis. — The  outlook  is  controlled  entirely  by  the  cause. 
If  the  result  of  congestion  of  the  brain  or  a  syphilitic  tumor,  the 
prognosis  is  favorable.  If  associated  with  hemiplegia,  the  clot  may 
undergo  absorption,  and  recovery  follow.  If  associated  with  soften- 
ing of  the  brain,  however,  the  disease  grows  progressively  worse. 

Treatment. — The  cause  must  be  energetically  treated,  as  the 
aphasia  pursues  a  course  parallel  to  the  associated  malady.  Cases 
not  associated  with  cerebral  softening  have  regained  the  memory 
of  words  b}^  a  course  of  carefully  conducted  speech  lessons. 

When  the  aphasia  is  of  sudden  occurrence  it  is  strongly  significant 
of  injury  to  the  brain  by  a  spicule  of  bone  or  the  pressure  of  a  blood 
clot,  particularly  in  those  cases  in  which  there  is  a  histor}^  of  a  head- 
wound.  In  these  instances,  the  operation  of  trephining  may  be  of 
benefit  and  should  be  considered. 

VERTIGO 

Synonyms. — Dizziness;  giddiness. 

Definition. — Vertigo,  or  dizziness,  is  a  subjective  state,  in  which 
the  individual  aft'ected  (subjective  vertigo),  or  the  objects  about  him 
(objective  vertigo),  seem  to  be  in  rapid  motion,  either  of  a  rotary, 
circular,  or  to-and-fro  character. 

Causes. — The  etiology  of  an  attack  of  vertigo  depends  upon  the 
particular  variet}^. 

Ocular  vertigo  results  from  the  paresis  of  one  or  more  of  the  ocular 
muscles,  eye-strain,  or  astigmatism. 

Aural  or  auditory  vertigo  or  Meniere' s  disease,  results  from  disease 
of  the  semicircular  canals  and  cochlea.     Aleniere's  disease,  so-called. 


VERTIGO  565 

is  a  sudden  severe  vertigo,  the  result  of  either  a  hemorrhage  or  a 
serous  or  purulent  exudation  into  the  semicircular  canals,  or  a  sudden 
rise  of  tension  in  the  endolymph  or  perilymph. 

Gastric  vertigo  is  the  most  common  variety  and  results  from  either 
stomachic  or  intestinal  dyspepsia,  disordered  hepatic  function,  or  con- 
stipation. "The  mechanism  of  the  vertigo  is  complex.  There  are 
two  factors:  one  consists  in  the  toxic  effect  of  the  imperfectly  oxi- 
dized materials  which  accumulate  in  the  blood;  the  other  is  reflex. 
An  impression  made  on  the  end  organs  of  the  pneumogastric  in  the 
stomach  is  reflected  over  the  sympathetic  ganglia"  (Bartholow). 

Nervous  vertigo  is  associated  with  migraine,  sick  or  nervous  head- 
ache, and  may  be  caused  by  physical  or  nervous  excesses,  and  also  by 
the  immoderate  use  of  tea,  coffee,  alcohol,  and  tobacco.  It  is  also  a 
result  of  many  of  the  organic  diseases  of  the  brain. 

Senile  vertigo  is  the  result  of  the  disordered  cerebral  circulation 
resulting  from  senile  changes  in  the  heart  and  vessels. 

S3miptoms. — In  all  varieties  of  vertigo,  the  symptom  of  a  sensation 
of  objects  moving  around  the  patient,  or  the  patient  moving  around  ob- 
jects which  remain  stationary,  is  present  in  some  degree.  The  attack 
of  giddiness  comes  on  suddenly,  with  an  indistinctness  of  vision  and 
slight  confusion  of  the  thoughts.  The  patient  may  faU  unless  he 
grasps  something  to  steady  himself.  Nausea  and  vomiting  and  cardiac 
palpitation  with  tinnitus  aurium  are  often  associated  with  the  ver- 
tiginous sensations.     There  is  no  loss  of  consciousness. 

In  the  ocular  vertigo,  the  attack  is  usually  the  result  of  reading, 
writing,  sewing,  or  other  close  application  of  the  eyes,  the  ordinary 
symptoms  of  vertigo  being  preceded  by  headache,  nausea,  specks 
before  the  eyes,  and  pain  in  the  eyeballs. 

In  Meniere's  disease,  the  vertigo  is  paroxysmal,  and  is  associated 
with  serious  tinnitus  aurium,  and  the  vertiginous  sensations  are  of 
various  forms  such  as  a  see-saw  movement,  a  gyratory  motion,  right 
or  left;  a  vertical  whirl,  or  a  sensation  of  rising  and  falling  like  the 
swell  of  the  ocean.  The  symptoms  are  of  long  duration,  becoming 
marked  in  paroxysms.  The  attack  of  aggravated  vertigo  is  so  sudden 
and  overwhelming  at  times,  that  the  person  is  suddenly  thrown  to  the 
ground  as  if  struck  with  a  blow,  and  is  associated  with  nausea  and 
vomiting.  As  the  condition  continues,  the  character  of  the  individual 
changes,  becoming  morose,  irritable,  and  suspicious.  Not  all  cases 
of  Meniere's  disease  become  permanent;  it  may  occur  in  isolated 
attacks,  the  interval  being  free  from  all  sensations. 


566  "  VERTIGO 

Gastric  vertigo  is  by  far  the  most  frequent  variety.  Persons  subject 
to  vertigo  of  this  kind  Hve  in  constant  dread  of  cerebral  disease,  which 
fear  frequently  results  in  true  melancholia. 

The  vertiginous  sensations  usually  occur  during  the  course  of  well- 
marked  and  long-standing  stomach  and  intestinal  disorders,  such  as 
pain  or  oppression  after  meals,  nausea,  pyrosis,  heartburn,  frequent 
eructations,  and  constipation  or,  rarely,  diarrhea.  The  abdomen  is 
often  distended  with  flatus.  Great  pain  in  the  nucha  is  a  very  fre- 
quent occurrence.  The  attack  may  be  associated  with  either  hyper- 
emia or  anemia  of  the  brain.  The  symptoms  are  not  constant,  but 
recur  at  intervals,  sometimes  remote,  at  others  very  close  to  each 
other. 

In  nervous  vertigo  the  vertiginous  symptoms  are  usually  associated 
with  more  or  less  irritability  of  temper,  restlessness,  and  insomnia. 
The  onset  is  sudden,  after  some  one  of  the  etiological  factors.  In 
migraine  there  are  headache,  nausea,  and  vomiting.  This  form  of 
vertigo  often  precedes  or  replaces  the  epileptic  convulsion.  And  it 
also  often  precedes  softening  of  the  brain. 

In  senile  vertigo  the  vertiginous  symptoms  are  the  result  of  anemia 
of  the  brain.  The  attacks  are  developed  by  an  exertion,  often  by 
merely  assuming  the  erect  posture.  There  is  a  swimming  sensation 
in  the  head,  and  darkness  falls  on  the  eyes,  with  a  sensation  of  chilli- 
ness and  prostration. 

Diagnosis. — The  diagnosis  of  the  various  forms  of  vertigo  can  only 
be  determined  after  a  close  study  of  the  history  and  course  of  the 
attack.  The  existence  of  organic  cerebral  disease  must  always  be 
kept  in  mind  in  solving  any  case. 

Prognosis. — This  will  be  influenced  by  the  variety  of  the  vertigo. 
The  prognosis  is  favorable  in  ocular  and  gastric  vertigo.  Unless  the 
result  of  organic  disease,  the  prognosis  is  good  in  nervous  vertigo. 
In  auricular  vertigo  the  prognosis  is  fair,  but  in  genuine  Meniere's 
disease  the  prognosis  is  unfavorable,  as  it  also  is  in  senile  vertigo. 

Treatment. — In  all  persistent  cases,  the  eyes  should  be  examined 
under  the  influence  of  a  cycloplegic  and  the  state  of  refraction  and 
muscle-balance  carefully  ascertained.  Correcting  lenses  should  be 
ordered  for  the  most  trivial  ametropic  condition  under  such  circum- 
stances, and  their  adjustment  should  receive  careful  attention. 

When  the  vertigo  is  that  of  Meniere's  disease,  rest  in  the  recumbent 
posture  and  the  administration  of  quinine  sulphate,  gr.  x  to  xv  (0.6 
to  I  gm.),  daily,  until  cinchonism  is  produced  is  advised  (Charcot). 


MIGRAINE  567 

In  cases  of  syphilitic  origin  the  iodides  may  be  employed.     Potassium 
bromide  and  the  salicylates  are  at  times  of  value. 

In  gastric  vertigo,  the  diet  should  be  carefully  regulated.  At  the 
beginning  of  the  treatment  it  is  often  of  great  advantage  to  place  the 
patient  on  an  exclusively  milk  diet,  gradually  widening  the  variety  as 
improvement  occurs.  In  these  cases  a  course  of  arsenic  is  often  ser- 
viceable. If  the  digestion  be  torpid,  the  tincture  of  nux  vomica  is 
indicated.  If  the  bowels  are  constipated,  benefit  is  obtained  from 
fluidextract  of  cascara. 

I^.     Glycerini f 5j  30  c.c. 

Fluidextract.  cascarae  sagr..  f  §3  30  c.c. 

Tinct.  card,  comp f  5ss  15  c.c. 

Aquae  menthae  pip fBss  15  c.c. 

M.   S. — One  teaspoonful  three  times  daily,   well  diluted. 

For  nervous  vertigo,  the  exciting  cause  should,  if  possible,  be  re- 
moved and  such  remedies  as  iron,  quinine,  and  strychnine,  either 
alone  or  in  various  combinations,  should  be  administered.  Many 
of  these  cases  can  be  traced  to  the  other  causes  of  vertigo  and  conse- 
quently the  treatment  is  subject  to  many  and  great  var^'ations. 

For  senile  vertigo,  a  highly  nutritious  diet  with  the  judicious 
use  of  whiskey  is  indicated.  Other  tonics,  particularly  bichloride  of 
mercury,  arsenic,  nux  vomica,  and  nitroglycerin  are  of  value.  The 
tendency  toward  atonic  dyspepsia,  flatulency,  and  constipation  in 
the  aged  should  be  avoided  by  the  use  of  appropriate  drugs  and  other 
therapeutic  measures.  The  possibility  of  uncorrected  presbyopia  as 
a  cause  in  these  cases  should  be  remembered. 

In  all  varieties  of  vertigo,  the  patient  should  abstain  from  tea, 
coffee,  tobacco,  highly  seasoned  foods,  malt  liquors,  and  alcohol, 
unless  especially  indicated. 

MIGRAINE 

Synonyms. — Megrim;  hemicrania;  sick  headache;  bilious  head- 
ache. 

Definition. — A  unilateral  paroxysmal  pain  in  the  head,  accom- 
panied by  nausea,  often  vomiting,  intolerance  of  light  and  sound 
and  incapability  of  mental  exertion,  the  brain  being  temporarily 
prostrated  and  disturbed. 

Causes. — In  the  majority  of  patients,  the  nervous  predisposition 
to  migraine  is  inherited,  but  whether  inherited  or  acquired,  it  com- 


568  MIGRAINE 

monly  develops  about  puberty.  It  is  more  common  in  women  than 
in  men. 

Among  the  many  exciting  causes  are  disturbances  of  digestion, 
irritation  of  the  ovaries  or  uterus,  worry,  anemia,  exacting  mental 
labor,  sexual  excesses  and  insufficient  sleep,  and  eye-strain.  The 
causes  of  many  attacks,  however,  are  wrapped  in  mystery,  as  with 
the  best  of  care  the  attacks  seem  to  have  a  periodic  course. 

Sjrmptoms. — Attacks  of  migraine  occur  in  irregular  paroxysms, 
the  intervals  between  being  free  from  pain  or  nervous  disturbance. 
For  a  day  or  two  preceding  the  paroxysm  it  may  be  ascertained  that 
there  were  feelings  of  fatigue  or  mental  depression  without  apparent 
cause,  heaviness  over  the  eyes,  flatulency  and  indigestion. 

The  attack  proper  is  ushered  in  by  chilliness,  yawning,  nausea,  often 
vomiting,  and  general  muscular  soreness,  with  intolerance  of  light, 
flashes  before  the  eyes,  often  phantasms,  noises  in  the  ears,  incapability 
for  mental  exertion,  vertigo,  and  pain  of  a  sharp,  shooting  character, 
of  great  intensity  and  persistency,  localized  most  frequently  in  either 
the  frontal,  temporal,  or  occipital  regions  of  the  left  side;  at  the  same 
time  there  is  tenderness  over  the  whole  side  of  the  head.  Rarely 
the  pain  is  felt  on  the  right  side,  and  still  more  rarely  on  both  sides  at 
the  same  time.  The  nausea  and  other  digestive  symptoms  may 
follow  the  onset  of  the  pain  instead  of  preceding  it. 

There  is  more  or  less  disturbance  of  the  circulation,  temperature, 
and  secretions  of  the  painful  parts.  At  times  there  is  a  marked 
contraction  of  the  vessels,  with  the  face  pale,  the  eyes  shrunken,  and 
the  pupils  dilated;  again,  the  vessels  may  be  dilated,  when  the  face 
is  flushed,  the  conjunctivae  injected,  and  the  pupils  contracted. 
Motion,  sound,  and  light  aggravate  the  acute  suffering.  The  urine 
before,  during,  and  after  a  paroxysm  is  concentrated,  and  it  may  be 
that  the  excretion  of  uric  acid  is  associated  with  the  etiology  of 
migraine. 

The  attack  may  continue  with  more  or  less  intensity  from  a  few 
hours  to  two  or  three  days,  the  average  duration  being  twenty-four 
hours. 

Diagnosis. — The  symptoms  are  so  characteristic  that  an  error 
seems  impossible.  It  may,  however,  be  confounded  with  anemic 
headache,  hyperemic  headache,  dyspeptic  or  bilious  headache, 
and  neuralgic  or  rheumatic  headache.  The  pains  of  organic  brain 
disease  must  be  excluded. 

Prognosis.— While  few  cases  of  true  migraine  are  permanently 


MIGRAINE  569 

cured,  the  affection  is  free  from  danger  to  life.  In  a  fair  number  of 
cases  the  susceptibility  to  attacks  declines  as  the  person  advances 
in  years,  it  being  rarely  seen  after  fifty  years.  According  to  Herter, 
cases  of  migraine  of  the  ophthalmic  variety  appear  to  be  not  rarely 
followed  by  general  paralysis  of  the  insane.  When,  however,  appro- 
priate treatment  is  instituted  in  cases  due  to  eye-strain,  the  response 
is  very  prompt  and  the  afifection  disappears  almost  immediately 
and  does  not  recur. 

Treatment. — To  abort  an  attack  of  migraine,  or  to  dispel  a  paroxysm 
after  its  onset,  rest  in  bed  in  a  quiet  and  darkened  room,  suitable 
diet,  and  the  administration  of  morphine  sulphate,  gr.  ^  (0.016  gm.), 
with  atropine  sulphate,  gr.  3i'2  0  (0.00054  gm.),  hypodermically, 
ant^'pyrin  gr.  xx  (1.3  gm.),  or  phenacetin,  gr.  x  (0.6  gm.),  should  be 
advised.  The  following  combination  frequently  relieves  the 
paroxysm : 

I^.     Phenacetin gr.  xx  1.3  gm. 

CaflEein.  citrat gr.  v  0.3  gm. 

Camphorae  monobrom gr.  xx  1.3  gm. 

M.     Ft.  capsule  No.  x. 

S. — One  every  two  hours  until  relief. 

In  many  attacks,  fluidextract  of  cannabis  indica,  lUij  to  iij 
(0.12  to  0.2  c.c),  every  half  hour  or  hour  for  a  number  of  doses,  alone 
or  combined  with  fluidextract  of  gelsemium,  in  the  same  dose,  is 
curative.  When  the  attacks  are "  associated  with  contraction  of  the 
vessels,  the  following  is  of  value: 

I^.     Potassii  bromid gr.  xxx  2 .0      gm. 

Morphinae  sulph gr.  3^  0.016  gm. 

vel 

Codeinae  sulph gr.  j  o .  065  gm. 

vel 

Tr.  opii  deodorat TTtxxx  2.0      c.c. 

Aquas  menth.  pip.,  .q.  s.  ad  f  5ss  ad     15.0       c.c. 
M.  S. — One  dose.     To  be  repeated  as  the  occasion  requires. 

Locally,  the  application  of  menthol  pencils  to  the  seat  of  the  pain 
is  beneficial.  The  inhalation  of  spirits  of  camphor  may  at  times 
afford  relief. 

During  the  interval,  a  careful  investigation  should  be  made  to 
determine  the  underlying  cause,  and  its  removal  should  then  be 
accomplished.     As  most  individuals  possess  ametropia  in  varying 


570  ACUTE   HYDROCEPHALUS 

degrees,  the  eye-strain  factor  in  the  etiology  should  be  immediately 
eliminated  by  proper  examination  of  the  eyes  under  cycloplegia  and 
the  prescribing  of  correcting  lenses  in  all  cases.  Frequently  this 
will  be  sufficient.  It  may  be  added,  that  not  uncommonly  the  in- 
stillation of  a  cycloplegic,  such  as  homatropine  or  atropine,  will 
relieve  an  attack.  Such  drugs  are  contra-indicated  if  presbyopia 
is  present,  but  it  should  also  be  remembered  that  migraine  is  rather 
infrequent  in  persons  past  forty-five  years  of  age. 

The  gastrointestinal  tract  is  responsible  for  a  large  number  of  cases 
and  quite  often  the  individual  paroxysms  may  be  traced  directly  to 
some  dietetic  indiscretion.  Such  cases  require  careful  regulation  of 
the  diet,  eliminating  substances  which  are  known  to  disagree  with  the 
patient.  The  use  of  tea,  coffee,  alcohol,  and  tobacco  should  be  re- 
duced to  a  minimum.  Constipation  should  always  be  avoided.  In 
all  cases,  extract  of  cannabis  indica,  gr.  ^  (0.016  gm.),  three  times 
daily  for  several  months  is  of  value. 

When  there  is  any  apparent  anemia,  tonics  such  as  iron,  quinine, 
strychnine,  and  arsenic  should  be  prescribed  together  with  good  food, 
fresh  air,  and  regulated  exercise. 

ACUTE  HYDROCEPHALUS 

Synonjrms. — ^Acquired  hydrocephalus;  serous  apoplexy. 

Definition. — Strictly  speaking,  hydrocephalus  signifies  water  in  the 
brain,  but  it  is  here  restricted  to  the  presence  of  a  serous  fluid  in  the 
arachnoid  spaces,  in  the  pia  mater,  in  the  ventricles,  and  in  the  brain 
substance  (edema) ;  characterized  by  the  more  or  less  sudden  develop- 
ment of  cerebral  excitation,  followed  by  depression  and  usually  death. 

Causes. — The  affection  is  most  common  between  the  ages  of  one 
and  five  although  it  may  occur  at  any  age.  A  neurotic  temperament 
is  a  rather  strong  predisposing  factor.  Among  the  exciting  causes 
are  unfavorable  hygienic  conditions,  dentition,  eruptive  fevers,  blows 
on  the  head,  mechanical  causes  preventing  the  return  of  the  blood 
from  the  veins  of  Galen  and  the  right  lateral  sinus,  compression  of 
the  jugular  vein,  acute  leptomeningitis,  diseases  of  the  right  heart, 
and  Bright's  disease. 

Pathological  Anatomy. — The  effusion  may  be  limited  to  the  ven- 
tricles, although  there  is  usually  considerable  distention  of  the  sub- 
arachnoid spaces  and  edema  of  the  pia  mater  and  neighboring  por- 
tions' of  the  brain,  whence  results  more  or  less  softening,  especially 


CONGENITAL   HYDROCEPHALUS  57 1 

around  the  ventricles.  The  choroid  plexus  is  hyperemic  and  may  be 
the  seat  of  minute  extravasations. 

Symptoms. — According  to  the  grouping  of  the  principal  symptoms, 
acute  hydrocephalus  may  be  considered  as  of  three  varieties,  simple, 
convulsive,  and  comatose. 

Simple  acute  hydrocephalus  is  most  common  in  children,  and  begins 
with  feverishness,  headache,  vertigo,  photophobia,  restlessness,  noc- 
turnal delirium,  insomnia,  twitching,  spasmodic  contractions  of  the 
muscles,  and  great  hyperesthesia  of  the  skin.  Such  symptoms  con- 
tinue for  several  days,  when  convulsions  occur,  followed  by  death  or 
a  continuance  of  the  symptoms,  followed  by  rigidity,  stupor,  and 
death. 

Convulsive  variety,  usually  the  result  of  Bright's  disease  or  a  general 
dropsy,  is  ushered  in  with  headache,  nausea,  and  vomiting,  followed 
in  a  day  or  two  by  convulsions,  passing  into  coma,  which  usually 
terminates  fatally,  although  rarely  a  remission  may  precede  death  for 
a  day  or  two. 

Comatose  variety,  known  also  as  ''serous  apoplexy,"  begins  abruptly 
with  the  phenomena  of  apoplexy,  the  result  of  the  sudden  effusion. 
The  pressure  is  usually  so  great  on  the  medulla  oblongata  that  it 
ceases  to  functionate,  death  resulting  usually  in  a  few  hours,  rarely 
several  days. 

Prognosis. — Unfavorable. 

Treatment. — The  underlying  disease  should  receive  careful  atten- 
tion and  the  symptoms  should  be  relieved  as  they  arise.  An  attempt 
may  be  made  to  remove  the  fluid  by  diuretics  and  full  doses  of  potas- 
sium iodide. 

CONGENITAL   HYDROCEPHALUS 

S5mon3nm. — Chronic  hydrocephalus. 

Definition. — An  excessive  accumulation  of  the  cerebrospinal  fluid, 
a  cerebral  dropsy;  in  the  ventricles,  internal  hydrocephalus,  or  in  the 
meshes  of  the  pia-arachnoid,  external  hydrocephalus,  or  in  both,  mixed 
hydrocephalus;  characterized  by  enlargement  of  the  head  and  more  or 
less  pronounced  nervous  phenomena. 

Causes. — It  is  a  disease  of  infants  and  young  children,  and  is  de- 
veloped in  the  prenatal  period.  The  affection  occurs  usually  in  the 
offspring  of  tuberculous,  scrofulous,  or  syphilitic  parents.  It  may 
arise  from  imperfect  or  arrested  development  of  the  brain  or  its  mem- 
branes and  from  inflammatory  changes  in  the  ventricles  and  epen- 


572  CONGENITAL   HYDROCEPHALUS 

dyma.  Occlusion  of  the  passages  by  which  the  ventricles,  and  ventri- 
cles and  subarachnoid  space  communicate  is  a  cause  in  many  cases. 

Pathological  Anatomy. — Enlargement  of  the  head  is  the  chief  exter- 
nal manifestation,  but  there  is  no  constant  ratio  between  the  size  of 
the  head  and  the  amount  of  fluid,  the  quantity  varying  from  an  ounce 
to  a  pint  or  more.  The  liquid  is  transparent,  of  a  straw  color,  con- 
taining a  small  amount  of  albumin  and  chloride  of  sodium.  If  the 
quantity  of  fluid  be  small,  the  ventricles  are  simply  distended;  if  the 
amount  be  large,  the  optic  thalami  and  corpus  striatum  are  depressed 
and  flattened,  the  roof  of  the  ventricles  thinned,  and  the  foramen  of 
Monro  is  greatly  enlarged.  The  enlargement  of  the  head  may  occur 
before  birth  and  impede  or  prevent  natural  delivery,  or  the  head  may 
be  normal  at  birth  and  increase  afterward.  As  enlargement  progresses, 
the  bones  are  so  thinned  as  to  be  translucent;  the  fontanelles  and 
sutures  are  widened;  the  lateral  portions  of  the  cranium  project;  the 
forehead  bulges  out  over  the  eyes;  and  the  orbital  plates  are  depressed, 
forcing  the  eyes  outward  and  downward,  producing  a  variety  of 
exophthalmos;  and  the  head  has  an  irregular,  triangular  shape,  the 
base  of  the  triangle  being  the  top  of  the  head.  The  scalp  being 
stretched  by  the  pressure  within,  becomes  tense  and  thin,  and 
scantily  covered  with  hair ;  and  the  veins,  which  ramify  in  it,  are  usually 
prominent  and  large,  and  the  entire  head  is  elastic  on  pressure,  from 
the  amount  of  liquid  beneath. 

Hilton  believed  that  the  accumulation  of  fluid  constituting  this 
disease  was  due  entirely  to  an  obstruction  in  the  opening  between  the 
fourth  ventricle  and  the  spinal  canal. 

Symptoms. — The  first  manifestation  of  the  disease  to  attract  atten- 
tion is  the  increased  size  of  the  head  in  an  emaciated  child  whose 
appetite  is  good  and  who  seemingly  partakes  of  food  well.  The  head 
appears  too  heavy;  the  eyes  are  prominent  and  have  a  downward 
direction;  the  face  is  devoid  of  expression,  old  and  wrinkled,  the  voice 
feeble;  and  the  mental  development  is  not  in  keeping  with  the  age. 
When  the  period  for  standing  or  walking  arrives,  the  power  is  found 
wanting.  The  further  history  is  but  a  continuation  and  exaggeration 
of  this  state,  until  convulsions  occur,  which  sooner  or  later  terminate 
fatally.  The  course  of  congenital  hydrocephalus  is  usually  slow, 
but  becomes  progressively  worse.  The  majority  terminate  within 
the  first  year;  cases  are  recorded,  however,  of  ten  and  fifteen  years' 
duration. 

Diagnosis. — In  rachitis  the  volume  of  the  head  is  increased,  due, 


SPINAL   HYPEREMIA  573 

in  part,  at  least,  to  a  deposit  of  calcareous  matter  on  the  exterior 
of  the  cranial  bones.  Rachitis  may  be  mistaken  for  hydrocephalus 
in  cases  in  which  the  amount  of  liquid  is  small.  The  dififerential 
diagnosis  is  based  on  the  shape  of  the  head — round  in  rachitis,  square 
or  triangular  or  with  prominences  in  hydrocephalus,  with  the  persist- 
ent downward  direction  of  the  eyes  and  the  elasticity  of  the  head 
on  pressure. 

Prognosis. — Unfavorable.  Arrest  of  progress  and  even  cures 
have  been  reported.  Spontaneous  cures  have  been  reported  follow- 
ing the  accidental  discharge  of  the  fluid,  but  such  reports  are 
exceptional. 

Treatment. — The  use  of  the  finest  aspirator  needle  to  evacuate 
the  fluid  is  fully  justifiable.  The  proper  situation  for  the  puncture 
is  the  coronal  suture,  about  i  or  i}i  inches  from  the  anterior  fon- 
tanelle.  Firm  but  gentle  compression  of  the  cranium  with  adhesive 
strips  should  be  made  during  the  escape  of  the  fluid  and  afterward. 
A  few  ounces  of  fluid  only  should  be  withdrawn  at  a  time.  The  in- 
ternal use  of  potassium  iodide  is  recommended.  All  measures  which 
tend  to  promote  constructive  metamorphosis  are  to  be  employed. 

DISEASES  OF  THE  SPINAL  CORD 

SPINAL  HYPEREMIA 

Synonym. — Spinal  congestion. 

Definition. — An  abnormal  fullness  of  the  vessels  of  the  meninges 
and  cord;  active  when  an  arterial  hyperemia;  passive  w^hen  a  venous 
hyperemia;  characterized  by  a  pain  in  the  back,  w^ith  more  or  less 
pronounced  disorders  of  sensation  and  locomotion. 

Causes. — Cold  and  exposure;  arrested  menses;  arrest  of  a  habitual 
hemorrhoidal  discharge;  malaria;  protracted  erect  posture;  injuries 
to  the  back;  certain  spinal  poisons,  as  strychnine,  picrotoxin,  and 
alcoholic  excesses. 

Pathological  Anatomy. — Active.  The  post-mortem  appearances 
are  congestion  of  the  meninges  and  cord,  the  same  vessels  supplying 
both,  with  numerous  points  of  extravasation,  due  to  the  rupture  of 
capillary  vessels.     The  spinal  fluid  is  increased  in  amount. 

Passive.  A  general  bluish  discoloration,  owing  to  the  abnormal 
fullness  of  the  large  anastomosing  vessels ;  the  spinal  fluid  is  somewhat 
increased. 


574  SPINAL   HYPEREMIA 

Symptoms. — Active  hyperemia  is  manifested  by  dull  pain  in  the 
dorsal  or  lumbar  region,  shooting  into  the  hips  and  thighs,  persistent 
and  increased  by  pressure;  tenderness  on  motion;  tingling  sensations 
in  the  limbs  and  feet,  and  sometimes  in  the  hands  and  arms;  a 
feeling  of  constriction  about  the  abdomen  is  often  present,  with 
rigidity  of  the  abdominal  muscles;  increased  reflexes,  with  disorders  of 
motility,  and  when  the  patient  is  in  the  recumbent  position,  jerking 
of  the  limbs.  Walking  is  accomplished  with  difficulty,  from  an  in- 
complete loss  of  power.  If  the  upper  part  of  the  cord  be  affected, 
dyspnea  and  palpitation  will  occur.  There  may  also  occur  painful 
priapism  and  frequent  nocturnal  emissions. 

The  above  symptoms  may  be  followed  by  a  more  or  less  pro- 
nounced temporary  depression,  the  sensation  diminished,  and  the 
lower  limbs  benumbed  and  heavy,  the  movements  being  weak. 
The  electro-contractility  is  preserved,  and  in  many  cases  even  in- 
creased or  exaggerated. 

Duration. — The  affection  lasts  from  a  few  hours  to  several  days, 
and  when  unduly  prolonged  terminates  in  myelitis. 

Diagnosis. — Anemia  causes  more  or  less  spinal  irritability  and 
tenderness;  but  the  history,  pallor,  and  general  weakness,  unasso- 
ciated  with  defects  of  motility  or  sensibility,  will  prevent  error. 

Spinal  meningeal  hemorrhage  is  more  sudden  in  its  onset,  is  more 
violent,  and  has  a  greater  range  of  symptoms  than  spinal  hyperemia. 

Myelitis  and  spinal  meningitis  have  symptoms  in  common  with 
spinal  congestion,  which  will  be  pointed  out  when  discussing  those 
conditions. 

Prognosis. — The  outlook  is  favorable,  recovery  usually  taking 
place  in  three  or  four  days.  If  the  symptoms  show  a  tendency  to 
linger,  myelitis,  more  or  less  pronounced,  will  ensue. 

Treatment. — Rest  is  indicated,  but  the  patient  should  avoid  lying 
on  the  back.  Cups  or  leeches  should  be  applied  along  the  spine  fol- 
lowed either  by  the  iced  or  the  hot  douche  or  hot  sponges.  Active  pur- 
gation should  be  brought  about  to  lessen  the  blood-pressure.  When 
the  condition  is  due  to  arrested  perspiration  a  hot-air  bath  and  the 
administration  of  pilocarpine  are  of  value.  When  it  follows  arrest 
of  the  menses,  aconite  will  be  of  benefit.  If  associated  with  a  very 
active  circulation,  potassium  bromide,  fluidextract  of  gelsemium,  ITlv 
(0.3  c.c),  or  fluidextract  of  ergot,  f  5ss  to  j  (2  to  4  c.c),  will  afford 
great  relief. 

In  passive  hyperemia  the  cause  should  be  ascertained  and  removed. 


SPINAL   PACHYMENINGITIS  575 

Ergot,    digitalis,   tonics,    and   purgatives   will   serve   to   lessen   the 
congestion. 

SPINAL  PACHYMENINGITIS 

S3'Tion3mis. — Hypertrophic  pachymeningitis ;  pseudo-membranous 
pachymeningitis . 

Defiiiition. — An  inflammation  of  the  inner  surface  of  the  spinal 
dura  mater  characterized  by  an  exudation  upon  this  inner  surface, 
attended  by  violent  pains  in  the  head,  neck,  shoulders,  and  arms, 
followed  by  muscular  contractures  and  paralyses  of  the  upper 
extremities. 

Causes. — Exposure  to  cold  and  damp,  alcoholism,  syphilis,  gout, 
and  injuries  are  most  common  causes.  It  may  be  secondary  to  Pott's 
disease. 

Pathological  Anatomy. — Hypertrophic  pachymeningitis  is  charac- 
terized by  an  exudation  upon  the  inner  surface  of  the  spinal  dura  mater, 
which  gradually  solidifies  into  a  layer  of  compact  connective  tissue. 
This  membrane  presses  upon  the  spinal  cord  and  nerves  producing 
myelitis  and  neuritis  with  subsequent  muscular  atrophy.  The  most 
frequent  seat  of  this  form  of  the  affection  is  the  cervical  region  and  it 
is  then  termed  cervical  hypertrophic  pachymeningitis . 

In  the  pseudo-membranous  variety,  an  exudation  also  forms  in 
which  large  numbers  of  blood-vessels  develop  and  rupture,  the  re- 
sulting extravasation  forming  a  cyst  or  hematoma  which  exerts  con- 
siderable pressure  on  the  cord  and  nerves. 

Symptoms. — The  onset  is  slow  and  gradual,  with  irregular  chills 
and  feverishness,  more  or  less  continuous  violent  pains  with  stiffness 
in  the  head,  neck,  shoulders,  and  arms,  and  a  painful  sense  of  con- 
striction of  the  upper  thorax.  Numbness  and  pricking  in  the 
arms  are  often  present.  Occasionally  nausea  and  vomiting  occur. 
These  symptoms  may  continue  in  varying  degrees  of  severity  for  sev- 
eral months,  the  muscles  of  the  painful  parts  ultimately  undergoing 
atrophy,  followed  by  spasmodic  contraction,  particularly  of  the  hands 
and  wrists,  and  eventually  by  paralysis.  The  paralytic  stage  develops 
gradually  with  weakness  in  the  arms  associated  with  contractures 
and  rigidity.  The  pain  continues  and  there  may  be  anesthesia, 
hyperesthesia,  or  paresthesia.  Trophic  changes  are  common.  Later, 
there  develop  paraplegia  with  rigidity,  exaggerated  reflexes  and 
spinal  epilepsy.  The  electro-contractility  is  lost.  It  has  been  ob- 
served, clinically,  that  the  immediate  cause  of  death  in  chronic  cere- 


576  SPINAL  MENINGITIS 

bral  and  spinal  disease  is  to  be  found  in  an  intercurrent  attack  of 
nephritis  or  tuberculosis. 

Prognosis. — If  early  recognized  and  promptly  treated,  the  hyper- 
trophic form  may  be  improved.  Generally,  however,  the  prognosis  is 
unfavorable. 

Treatment. — Rest  in  bed  with  repeated  counterirritation  over  the 
spine  is  indicated.  The  diet  should  be  highly  nutritious  and  drugs 
such  as  cod-liver  oil,  hypophosphites,  and  potassium  iodide  should  be 
administered.  The  various  symptoms,  such  as  pains  and  spasms, 
should  be  treated  as  they  arise  on  general  principles. 

SPINAL   MENINGITIS 

Synonym. — Spinal  leptomeningitis. 

Definition. — Inflammation  of  the  arachnoid  and  pia  mater  mem- 
branes of  the  spinal  cord,  either  acute,  subacute,  or  chronic;  charac- 
terized by  pain  in  the  back,  rigidity  of  the  muscles,  and  disorders  of 
motility  and  sensibility. 

Causes. — The  disease  is  rare  and  is  nearly  always  due  to  an  infec- 
tion. Cerebrospinal  meningitis,  tuberculosis,  syphilis,  typhoid  fever, 
septicemia,  traumatism,  and  exposure  are  the  most  common  causes. 

Pathological  Anatomy. — The  acute  form  is  attended  by  hyperemia 
of  the  membranes  with  swelling  of  the  tissues,  the  result  of  serous 
infiltration,  followed  by  purulent  and  fibrinous  exudations.  The 
roots  of  the  spinal  nerves  are  covered  with  exudation,  and  are 
swollen  and  soft.  The  cord  proper  is  more  or  less  congested  and 
edematous. 

In  the  chronic  form,  there  is  adhesion  of  the  membranes,  with  more 
or  less  accumulation  of  fluid,  resulting  in  atrophic  degeneration  of  the 
cord  from  pressure.  When  the  disease  is  tuberculous  in  origin,  granu- 
lations are  seen  distributed  over  the  pia,  arachnoid,  and  inner  sur- 
face of  the  dura. 

Symptoms. — There  are  two  stages:  the  first,  the  stage  of  irritation; 
the  second,  the  stage  of  paralysis  of  motion  and  sensation,  with 
atrophy.  The  onset  is  marked  by  rigor  and  pyrexia,  with  intense 
boring  pain  in  the  back,  aggravated  by  motion,  rigidity  of  the  spine, 
and  a  sense  of  constriction  around  the  body — the  "girdle  sensation." 
Spasmodic  contractions  of  the  muscles  supplied  by  the  nerves  origi- 
nating at  the  seat  of  the  lesion,  with  inability  to  straighten  the  limbs 
are  also  present.     If  the  lower  part  of  the  spinal  membranes  is  the 


SPINAL   MENINGITIS  577 

seat,  there  occur  retention  of  urine  and  constipation ;  if  the  upper  part, 
dysphagia,  dyspnea,  and  feeble  heart.  If  the  inflammation  extend  to 
the  medulla,  the  above  symptoms  are  associated  with  disorders  of 
speech,  vomiting,  and  delirium.  The  muscular  contractions  are  ex- 
cited or  increased  by  motion,  but  uninfluenced  by  pressure.  Reflex 
movements  are  not  abolished,  and  may  be  exaggerated.  The  rigidity 
and  spasmodic  contractions  of  the  muscles  are  followed  by  paralysis, 
more  or  less  complete,  death  ensuing  from  paralysis  of  the  muscles 
of  respiration. 

Electro-contractility  is  lessened  or  absent,  both  as  to  motility  and 
sensibility  in  the  affected  parts. 

The  chronic  form  succeeds  to  the  acute  or  originates  spontaneously, 
and  presents  the  same  form  and  order  of  symptoms — excitation  or 
irritation,  and  depression  or  paralysis. 

Diagnosis. — The  points  of  importance  are :  deep,  boring  pain  in  the 
back,  aggravated  by  motion  but  not  by  pressure,  with  spasmodic  con- 
traction of  the  muscles,  followed  by  paralysis. 

Myelitis  is  marked  by  slight,  or  no  pain,  with  earlier  and  more  com- 
plete paralysis. 

Tetanus  may  be  confounded  with  spinal  meningitis.  The  points 
of  distinction  are:  in  the  former  occur  early  trismus  with  rhythmic 
spasms  excited  by  irritation  of  the  skin,  whereas  irritation  of  the  skin 
does  not,  in  spinal  meningitis,  produce  muscular  contractions,  but 
movement  of  the  limbs  does;  tetanus  progressively  increases,  and  is 
not  associated  with  fever;  there  is  usually  a  clear  history  of  an  injury. 

Prognosis. — Generally  unfavorable.  Death  is  either  sudden,  from 
paralysis  of  respiration  and  of  the  heart,  or  gradual,  the  result  of 
exhaustion. 

Critical  discharges,  such  as  profuse  perspiration,  urinary  flow,  or 
epistaxis  occasionally  occur,  and  are  followed  by  rapid  recovery. 
Cases  recovering  may  have  more  or  less  pronounced  partial  or  com- 
plete paralysis. 

Treatment. — The  patient  should  be  placed  at  rest  in  bed  and  al- 
lowed to  lie  on  the  side  or  face.  Cups  or  leeches  should  be  applied 
along  the  spine,  followed  by  ice,  the  hot  douche,  hot  sponges,  or  mus- 
tard. Free  purgation  should  be  obtained.  In  cases  due  to  syphilis, 
mercury  and  the  iodides  should  be  given  in  full  doses.  In  the  para- 
lytic stage,  quinine  sulphate,  gr.  iij  (0.2  gm.),  with  alcoholic  extract 
of  belladonna,  gr.  3^  (0.16  gm.),  three  times  daily,  is  often  of  great 
value.  The  galvanic  current  should  be  applied  to  the  spine  and  to  the 
37 


578  [acute  myelitis 

nerve  trunks  and  the  faradic  current  to  the  affected  muscles.     Deep 
injections  of  strychnine  and  massage  should  also  be  employed. 

ACUTE  MYELITIS 

Synonjrms. — Acute  or  general  diffuse  myelitis;  transverse  myelitis; 
softening  of  the  cord. 

Definition. — An  inflammation  affecting  the  substance  of  the 
spinal  cord,  which  may  be  limited  to  the  gray  or  white  matter,  and 
may  involve  the  whole  or  isolated  portions  of  the  cord.  When  the 
gray  matter  alone  is  inflamed,  it  is  termed  central  myelitis;  when  the 
white  matter  and  the  meninges,  it  is  termed  cortical  myelitis;  it  may 
be  ascending,  descending,  or  transverse  in  its  extension.  The  disease 
is  characterized  by  more  or  less  sudden  and  complete  loss  of  motion 
and  sensation. 

Causes. — It  may  follow  acute  congestion  or  spinal  meningitis, 
or  it  may  be  due  to  exposure  to  cold  and  damp  or  wet  weather,  injuries 
to  the  vertebrae,  syphilis,  rheumatism,  puerperal  fever,  typhus, 
typhoid,  small-pox,  diphtheria,  measles,  influenza,  gonorrhea,  or  to 
poisoning  by  lead,  arsenic,  or  mercury. 

Pathological  Anatomy. — The  substance  of  the  cord  is  intensely 
hyperemic  and  extravasations  are  scattered  throughout  it  giving  to 
the  tissues  a  reddish  brown  or  chocolate  tint.  Sometimes  prominent 
hemorrhagic  effusions  are  observed.  Serous  transudations  are  also 
present,  resulting  in  softening  of  the  structure  of  the  cord,  the  color 
changing  to  yellow  and  white;  the  nerve-elements  undergo  fatty 
degeneration  and  present  the  appearance  and  consistency  of  cream. 
The  membranes  are  involved  in  more  or  less  similar  changes.  The 
microscope  reveals  degeneration  of  the  cellular  elements  and  their 
replacement  by  fat  granules,  granular  debris,  and  blood  cells. 

SjnmLptoms. — The  severity  of  the  symptoms  depends  upon  the 
extent  and  location  of  the  inflammation. 

The  onset  is  usually  sudden,  with  a  chill,  fever,  io3°F.,  frequent 
pulse,  and  alterations  in  sensibility  and  motility — viz.,  pain  in  the 
back,  aggravated  by  touch  and  by  heat  and  cold,  with  sensations  of 
formication  ("pins  and  needles"),  the  limb  feeling  as  if  asleep,  or 
complete  anesthesia,  associated  with  severe  neuralgic  pains.  The 
sensation  of  constriction  aroimd  the  body  and  limbs,  as  if  encircled 
by  a  tight  cord,  the  "girdle  pains,"  is  a  characteristic  symptom,  and 
is  followed  by  a  rapidly  developing  paraplegia  which  becomes  complete 


ACUTE    MYELITIS  579 

in  a  few  hours  and  is  accompanied  by  involuntary  discharges.  The 
reflex  functions  are  usually  abolished,  as  seen  by  attempting  to  cause 
movement  of  the  limbs  by  tickling  the  feet  or  by  striking  the  patella 
tendon;  rarely  are  they  diminished,  very  rarely  exaggerated.  The 
temperature  of  the  affected  limbs  is  lowered  three  or  four  degrees. 
Sloughs  and  bed-sores,  and  muscular  atrophy  result  if  the  anterior 
cornua — the  trophic  centers — are  affected. 

The  symptoms  of  loss  of  motion  and  sensibility,  with  rectal  and 
vesical  paralysis,  are  associated  with  more  or  less  pronounced  vomit- 
ing, hepatic  disorders,  irregularity  of  the  heart,  dyspnea,  dysphagia, 
apnea,  and  painful  priapism.  The  urine  is  markedly  alkaline 
in  reaction,  finally  developing  cystitis.  Among  the  late  manifesta- 
tions are  shooting  pains  and  spasmodic  twitchings  or  contractions  of 
one  or  all  of  the  muscles  of  the  paralyzed  parts.  The  electro-con- 
tractility is  abolished  in  the  paralyzed  parts. 

Diagnosis. — The  principal  diagnostic  features  of  acute  myelitis 
are  the  ''girdle  sensation"  around  the  limbs  or  body,  rapid  and  com- 
plete paraplegia,  loss  of  sensation,  lowered  temperature  in  the 
affected  parts,  early  and  persistent  sloughing  (bed-sores),  and  alka- 
line urine  or  cystitis. 

The  diagnosis  of  the  location  of  the  lesion  is  made  by  a  study  of  the 
degree  of  the  anesthesia,  the  skin  reflexes,  and  the  distribution  and 
extent  of  paralysis,  which  are  shown  in  the  table  from  Dana  (page  580) . 

Acute  spinal  meningitis  is  distinguished  from  acute  myelitis  by 
severe  pains,  increased  by  pressure,  with  muscular  contractions 
increased  by  motion,  followed  by  paralysis  much  less  profound  than 
the  paraplegia  of  myelitis;  in  spinal  meningitis  there  exists  cutane- 
ous and  muscular  hyperesthesia,  which  are  absent  in  myelitis. 

Congestion  of  the  spinal  cord  is  characterized  by  the  mild  character 
and  short  duration  of  all  the  symptoms. 

Hemorrhage  in  the  spinal  cord  is  abrupt  with  irritative  symptoms, 
slight  paralysis,  preserved  reflexes  and  electro-contractility. 

Hysterical  paraplegia  shows  no  trophic  changes,  no  altered  re- 
flexes, slight  atrophy,  irregular  anesthesia,  contractures  with  im- 
paired sensation  of  the  contracted  limb,  and  the  presence  of  the 
stigmata  of  hysteria. 

Lithemic  paresthesia,  characterized  by  tingling  and  numbness  of 
fingers  and  toes,  might  lead  to  error  if  the  cerebral  symptoms  of 
lithemia  are  overlooked. 

Prognosis. — This  depends  upon  the  location  of  the  lesion  and 


580  ACUTE   MYELITIS 

Localization  of  the  Functions  of  the  Segments  of  the  Spinal  Cord 


Segment 


Muscles 


Reflex   and   centers 


Sensation 


First  cervical. 


Second  and  third 
cervical. 


Fourth  cervical. 


Fifth  cervical.  . 


Sixth  cervical. 


Seventh  cervical. 


Eighth  cervical. 


Rectus  lateralis. 
Rectus  capitis. 
Anticus   and  posti- 
cus. 
Sterno-hyoid. 
Stemo-thyroid. 
Sterno-mastoid. 
Trapezius. 
Scaleni  and  neck. 
Omo-hyoid. 
Diaphragm. 


Diaphragm. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Supinator-longus. 

Rhomboid. 

Supra-  and  infra- 
spinatus. 

Deltoid. 

Biceps. 

Coraco-brachialis. 

Brachialis  anticus. 

Supinator-longus. 

Supinator-brevis. 

Deep  muscles  of 
shoulder-blade. 

Rhomboid. 

Teres  minor. 

Pectoralis  (clavicu- 
lar part). 

Serratus  magnus. 

Deltoid. 

Biceps. 

Pectoralis  (clavicu- 
lar part). 

Serratus  magnus. 

■Triceps. 

Pronators. 

Brachialis  anticus. 

Subscapular. 

Rhomboid. 

Latissimus  dorsi. 

Triceps  (long  head).. 

Extensors  of  wrist! 
and  fingers. »  j 

Pronators  of  wrist. 

Flexors  of  wrist.        . 

Subscapular. 

Pectoralis  (costal).   , 

Latissimus  dorsi.  ; 
Teres  major. 

Triceps  (longhead).' 
Flexors  of  wrist  and 

fingers.  I 

Intrinsic  hand  mus-l 

cles.  ' 


Hypochondrium  _      (?). 

Sudden  inspiration 
produced  by  sudden 
pressure  beneath  the 
lower  border  of  ribs. 


Pupillary  (fourth  cer- 
vical to  second  dor- 
sal). Dilatation  of 
the  pupil  produced 
by  irritation  of  neck.i 


Scapular  (fifth  cer- 
vical to  first  dorsal). 
Irritation  of  skin 
over  the  scapula  pro- 
duces contraction  of 
scapular  muscles. 

Supinator  I  on  g  us  . 
Tapping  the  tendon 
of  the  supinator 
longus  produces  flex- 
ion of  forearm. 


Back  of  head  to  ver- 
tex and  neck  (oc- 
cipitalis major,  oc- 
cipitalis minor,  au- 
ricularis  magnus, 

superficialis  colli, 
and    supraclavicular). 

Neck. 

Shoulder,  anterior  sur- 
face. 

Outer  arm  (supra- 
clavicular, circum- 
flex, external  musculo- 
cutaneous, cutaneous). 

Back  of  shoulder  and 
arm. 

Outer  side  of  arm  and 
forearm  to  the  wrist 
(supraclavicular,  cir- 
cumflex, external 
cutaneous,  internal 
cutaneous,  posterior 
spinal  branches). 


Outer    side    and    front 
Triceps    (fifth  to   sixth      of  forearm, 
cervical).  Tapping   Back    of    hand,    radial 

elbow      tendon      pro-      distribution, 
duces      extension      of    (Chiefly    external 


forearm. 
Posterior     wrist     (sixth 
to     eighth     cervical) . 
Tapping  tendons 

causes     extension     of 
hand. 


Anterior      wrist      (sev 
enth    to    eighth    cer-j 
vical).    Tapping' 

anterior  tendons 
causes  flexionof 
wrist.  I 

Palmar  (seventh  cer- 
vical to  first  dorsal). 
Stroking  palm  causes 
closure  of  fingers. 


cutaneous,  internal  cu- 
taneous, radial.) 


Radial  distribution  in 
the  hand. 

Median  distribution 
in  the  palm,  thumb, 
index,  and  one-half 
middle  finger. 
(External  cutaneous, 
internal  cutaneous, 
radial,  median,  pos- 
terior spinal  branches.) 

Ulnar  area  of  hand, 
back  and  palm,  inner 
border  of  forearm 
(internal  cutaneous, 
ulnar) . 


ACUTE   MYELITIS 


581 


Localization   of   the   Functions  of  the  Segments  of  the  Spinal 

Cord. — Continued 


Segment 


Muscles 


Reflex  and  centers 


Sensation 


First  dorsal. 


Second  dorsal. 


Second  to  twelfth 
dorsal. 


First  lumbar. .  . . 

Second  lumbar. . 

Third  lumbar. .  . 
Fourth  lumbar. . 

Fifth  lumbar. . .  . 


Extensors  of  thumb. 

Intrinsic  hand  mus- 
cles. 

Thenar  and  hypo- 
thenar  muscles. 


Muscles  of  back  and 
abdomen. 
Erectores  spinas. 


First  and  second 
sacral. 


Third,        fourth, 
and  fifth 

sacral. 


None. 


Vastus  internus . . 


Sartorius ;       adduc- 
tors of  thigh. 
Flexors  of  thigh..  .  . 
Extensors  of  knee. 
Abductors  of  thigh 


Outward  rotators. 
Flexors  of  knee. 
Flexors  of  ankle. 
Peronei. 
Extensors  of  toes. 


Calf  muscles. 
Glutei.  _ 
Peronei. 

Extensors  of  ankle 
Small     muscles     of 

foot. 
Peronei. 
Muscles  of  bladder, 

rectum,  and  exter 

nal  genitals. 


Epigastric  (fourth  to 
seventh  dorsal). 
Tickling  mammary 
region  causes  retrac- 
tion of  the  epigas- 
trium. 

Abdominal  seventh 

to  eleventh  dorsal. 

Stroking  side  of  ab- 
domen causes  retrac- 
tion of  belly. 

Vaso-motor  centers. 

Second  dorsal  to  secondf 
lumbar. 

Cremasteric  (first  to 
third  lumbar). 
Stroking  inner  thigh 
causes  retraction  of 
scrotum. 

Patellar.  Striking 
patellar  tendon 
causes  extension  of 
leg. 


Gluteal  (fourth  to 
fifth  lumbar).  Strok- 
ing buttock  causes 
dimpling  in  fold  of 
buttock. 

Achilles  tendon.  Over- 
extension causes 
rapid  flexion  of  ankle, 
called  ankle  clonus. 


Plantar  (fifth  lumbar 
to  second  sacral) . 
Tickling  sole  of  foot 
causes  flexion  of  toes 
and  retraction  of  leg. 


Genital  center. 
Vesical  center. 
Anal  center. 


Chiefly  inner  side  of 
forearm  and  arm  to 
near  the  axilla. 
(Chiefly  internal  cu- 
taneous and  nerve 
of  Wrisberg  or  lesser 
internal    cutaneous.) 

Inner  side  of  arm  near 
and  in  axilla  (inter- 
costo-humeral). 

Skin  of  chest  and  ab- 
domen, in  bands 
running  around  and 
downward  correspond- 
ing to  spinal  nerves. 

Upper  gluteal  region 
(intercostals  and 
dorsal  posterior 
nerves) . 


Skin  over  groin  and 
front  of  scrotum 
(ilio-hypogastric,  ilio- 
inguinal) . 

Outer  side  and  upper 
front  of  thigh.  Lum- 
bar region  (geni- 
to-crural,  external 

cutaneous). 

Front  and  outer  side 
of  thigh.  Inner  side 
of  leg  and  foot. 

Inner  side  of  thigh, 
leg,  and  foot  (inter- 
nal cutaneous,  long 
saphenous,  obtura- 
tor). 

Back  of  thigh  and 
outer  side  of  leg  and 
ankle;  sole;  dorsum 
of  foot. 

(External  popliteal, 
external  saphenous, 
musculo  -  cutaneous, 
plantar) . 

Back  of  buttock  and 
thigh;  side  of  leg 
and  ankle;  sole;  dor- 
sum of  foot. 


Circumanal  region, 

anus,  rectum,  penis, 
urethra,  vagina, 
perineum  (small 
sciatic,  pudic,  inferior 
hemorrhoidal,  inferior 
pudendal"). 


582  ^BULBAR   PARALYSIS 

completeness  of  the  symptoms.  If  the  paralysis  is  of  the  ascending 
variety,  death  occurs  within  a  few  days,  from  paralysis  of  the  muscles 
of  respiration.  If  the  trophic  centers  are  affected,  there  occur  bed- 
sores, intense  pyelo-nephritis  and  cystitis,  and  changes  in  the  joints; 
death  results  from  exhaustion  in  several  weeks.  Central  myelitis, 
or  inflammation  of  the  gray  matter,  is  rapid  in  its  progress,  death 
occurring  in  a  week  or  two.  The  morbid  process  may  in  rare  in- 
stances be  arrested  and  the  general  health  restored,  but  some  spinal 
symptoms  will  persist. 

Treatment. — Absolute  rest  is  essential  to  even  secure  a  pallia- 
tion of  the  symptoms. 

Locally,  considerable  relief  follows  the  use  of  hot  water  bags 
or  sponges  dipped  in  hot  water  and  applied  along  the  spine  every  few 
hours. 

Internally,  digitalis,  strychnine  sulphate,  ergot,  belladonna,  bro- 
mides, iodides,  cimicifuga,  quinine  sulphate,  and  other  similar  drugs 
may  be  employed  but  the  result  following  their  use  is  somewhat 
doubtful.  Careful  nursing  is,  however,  of  great  benefit.  Absolute 
cleanliness  and  frequent  change  of  posture  is  necessary  to  prevent 
bed-sores.  Retention  of  urine  should  be  avoided  by  frequent  aseptic 
catheterization.  Cystitis  should  be  treated  by  boric  acid  irrigations. 
The  condition  of  the  intestinal  tract  should  also  receive  attention. 
If  the  affection  shows  any  tendency  toward  recovery,  this  tendency 
should  be  stimulated  by  electricity  and  massage. 

BULBAR  PARALYSIS 

Synonyms. — Glosso-labio-pharyngo-laryngeal  paralysis;  progress- 
ive bulbar  paralysis. 

Definition.- — A  chronic  degenerative  affection  of  certain  nuclei 
of  the  medulla  oblongata,  characterized  by  a  slowly  progressive 
bilateral  paralysis  of  the  tongue,  lips,  palate,  pharynx,  and  larynx, 
with  atrophy  of  the  tongue  and  lips. 

Causes. — The  etiology  is  obscure.  It  rarely  occurs  before  the 
fortieth  year.  It  may  be  brought  about  by  extension  of  spinal  or 
cerebral  affections  to  the  medulla.  Among  other  etiological  influences 
may  be  mentioned  cold,  rheumatism,  gout,  syphilis,  and  injuries 
about  the  neck. 

Pathological  Anatomy. — The  structural  changes  consist  in  degenera- 
tive atrophy  of  the  gray  nuclei  in  the  floor  of  the  fourth  ventricle, 


BULBAI?   PARALYSIS  583 

with  atrophy  and  gray  discoloration  of  the  nerve-roots  from  the 
medulla,  especially  of  the  facial  and  hypoglossal  nerves.  The  motor 
ganglion-cells  atrophy  and  disappear  not  infrequently  being  the  only 
changes.  The  nerves  supplied  to  the  muscles  exhibit  sclerosis  of  the 
neurilemma,  and  degenerative  atrophy  is  found  in  the  nerve-roots 
coming  from  the  bulb. 

Symptoms. — The  disease  begins  insidiously.  There  is  first  noticed 
some  difficulty  in  articulation,  from  want  of  precision  in  movements 
of  the  tongue,  particularly  in  the  use  of  the  lingual  consonants,  /,  n, 
r,  and  /,  which  increases  until  that  organ  is  completely  paralyzed. 
The  paralysis  gradually  invades  the  soft  palate  and  pharyngeal  mus- 
cles, causing  difficulty  in  deglutition;  the  orbicularis  oris  preventing 
closure  of  the  lips;  the  laryngeal  muscles,  interfering  with  articula- 
tion. With  the  increasing  loss  of  power  in  the  tongue  and  lips  there 
is  also  a  gradual  atrophy  of  these  muscles ;  the  atrophy  usually  ante- 
dates the  paralysis.  When  the  disease  is  fully  developed,  the  condi- 
tion of  the  patient  is  most  pitiable;  articulation  is  impaired  or  impos- 
sible, and  deglutition  interfered  with,  the  lips  remaining  apart  allow- 
ing the  saliva  to  dribble  from  the  mouth  and  liquids  to  return  through 
the  nose  with  attempts  at  swallowing.  As  the  malady  progresses, 
the  pneumogastric  nucleus  becomes  involved,  resulting  in  loss  of 
voice,  difficulty  of  respiration,  and  cardiac  irregularity.  The  general 
health  gradually  suffers  from  insufficient  nutrition  and  imperfect 
respiration,  although  the  mind  is  clear  until  the  end.  The  ''reactions 
of  degeneration"  are  present. 

Besides  the  chronic  bulbar  paralysis,  there  are  two  acute  forms 
with  the  same  symptoms  as  the  chronic  cases,  only  they  develop 
suddenly,  one,  the  result  of  hemorrhage  into  the  medulla,  which 
at  the  onset  has  vertigo,  vomiting,  loss  of  power  in  the  limbs,  and 
slight  sensory  disturbances,  all  of  which  disappear,  leaving  the  glosso- 
labio-laryngeal  paralysis;  the  second  form  comes  suddenly,  with 
fever,  vomiting,  and  loss  of  power  in  the  limbs,  soon  disappearing, 
leaving  the  characteristic  bulbar  symptoms;  this  variety  is  inflam- 
matory and  closely  allied  to  acute  poliomyelitis. 

Diagnosis. — The  recognition  of  this  disease  is  not  difficult.  The 
paralysis  of  deglutition  is  particularly  characteristic. 

Prognosis. — The  acute  forms  terminate  fatally  within  a  few  days. 
The  chronic  form  lasts  from  one  to  five  years  and  ultimately  termi- 
nates in  death  from  exhaustion,  respiratory  failure,  or  cardiac  failure. 

Treatment. — The   treatment   is   entirely   symptomatic.     Feeding 


584         PROGEESSIVE  MUSCULAR  ATROPHY 

should  be  accomplished  by  the  stomach-tube  to  avoid  puhnonary 
aspiration.     Massage  and  galvanism  should  be  employed. 

PROGRESSIVE  MUSCULAR  ATROPHY 

Synonyms. — Wasting  palsy;  chronic  spinal  muscular  atrophy; 
chronic  poliomyelitis. 

Definition. — A  chronic  progressive  motor  paralysis  with  atrophy 
of  certain  groups  of  muscles.  The  paralysis  is  proportionate  to  the 
wasting  or  fibrillary  atrophy. 

Causes. — It  occurs  most  frequently  in  males  between  twenty-five 
and  fifty  years  of  age  and  in  many  instances  is  hereditary.  A  pre- 
disposition seems  to  exist  in  those  who  habitually  use  one  set  of  mus- 
cles (muscular  strain).  Exposure  to  cold  and  damp,  lead;  syphilis; 
injuries  to  the  spinal  column  and  acute  diseases  as  diphtheria,  measles, 
acute  rheumatism,  typhoid  and  typhus  fevers,  may  influence  it 
production. 

Pathological  Anatomy. — Two  theories  as  to  the  origin  of  the  patho- 
logical changes  are  held:  one  that  the  initial  lesion  is  in  the  cord 
(Charcot),  the  other,  in  the  muscular  interstitial  connective  tissue 
(Friedreich) . 

The  morbid  alterations  are  of  two  groups — spinal  and  muscular. 

The  spinal  changes  consist  in  the  atrophy  and  degeneration  of 
the  anterior  columns,  wasting  and  disappearance  of  the  multi-polar 
ganglion-cells  of  the  anterior  horns  with  hyperplasia  of  the  neuroglia; 
rarely,  the  hyperplasia  extends  to  the  lateral  columns  (amyotrophic 
lateral  sclerosis) ;  also  atrophy,  and  degeneration  of  the  anterior  nerve- 
roots. 

The  muscular  changes  consist  of  a  progressive  wasting  of  the  mus- 
cular tissue,  with  increase  of  the  interstitial  connective  tissue.  "The 
final  result  is  that  the  muscle  is  converted  into  a  mere  fibrous  band 
with  numerous  fat  cells,  the  development  of  this  latter  material  taking 
place  outside  of  the  muscular  elements  and  in  the  newly  formed  con- 
nective tissue  "  (Bartholow). 

Symptoms. — The  invasion  is  gradual,  the  disease  having  been  in 
progress  some  weeks  or  months  before  the  patient  is  aware  of  its 
existence. 

,  In  the  immense  majority  of  cases,  the  disease  is  permanently  limited 
to  one  or  a  few  groups  of  muscles  in  the  upper,  or  more  rarely  in  the 
lower,  extremities.  The  only  muscles  not  yet  known  to  be  attacked 
are  those  of  mastication  and  those  that  move  the  eyeball  (Roberts). 


PROGRESSIVE   MUSCULAR  ATROPHY  585 

Fibrillary  contraction  is  an  early  symptom,  continuing  more  or  less 
marked  so  long  as  any  muscular  fibers  remain.  It  consists  of  wave-like 
movements  of  the  muscles,  excited  automatically,  by  draughts  of  air 
or  percussion.  Coincident  with  the  wasting  there  occur  loss  of  power, 
disorders  of  sensation,  and  coolness  and  pallor  of  the  surface. 

The  natural  roundness  and  contour  of  the  body  and  limbs  are 
changed,  the  bones  standing  out  with  unusual  distinctness,  giving  the 
individual  the  appearance  of  a  skeleton  clothed  in  skin. 

Four  types  of  the  disease  are  recognized:  (i)  the  hand-type;  (2) 
the  juvenile  type;  (3)  the  infantile  facial  type;  (4)  the  peroneal  type. 

The  hand-type:  Wasting  begins  in  the  hand,  particularly  in  the 
short  muscles  of  the  thumb  and  the  ball  of  the  little  finger — the 
thenar  and  hypothenar  eminences.  The  complete  atrophy  of  the 
thumb  muscles  produces  such  a  change  in  the  shape  of  the  hand  as  to 
give  it  the  name  of  the  ape-hand.  Soon,  and  may  be  at  the  same  time, 
wasting  of  the  dorsal  interosseous  muscles  is  observed,  with  conse- 
quent loss  of  power  in  these  muscles,  producing  the  deformity  known 
as  claw-hand.  Shortly  the  deltoid  and  other  arm  muscles  are  involved 
in  the  wasting  and  contraction. 

The  juvenile  type  (Erb) :  A  rare  form,  affecting  the  muscles  of  the 
shoulder  and  upper  arm,  and  less  commonly  the  muscles  of  the  lower 
extremities.  This  form  follows  the  hand-type  after  a  time,  but 
Erb  described  cases  occurring  primarily  in  these  parts.  Rarely, 
wasting  in  the  suprascapular  muscles,  with  fibrillary  contractions, 
is  seen  alone. 

The  infantile  facial  type  involves  the  muscles  of  expression,  chang- 
ing entirely  the  appearance  of  the  individual  and  giving  the  eyeballs 
undue  prominence  from  atrophy  of  the  surrounding  muscles,  not 
unlike  exophthalmos.  After  a  time,  the  muscles  of  the  shoulder 
and  arm  are  involved,  except  the  supraspinatus,  infraspinatus,  and 
the  flexors  of  the  hand  and  fingers. 

The  peroneal  type:  Wasting  first  appears  in  the  muscles  of  the 
legs,  extending  to  the  feet,  producing  single  or  double  club-foot. 
After  a  time  the  muscles  of  the  hands  and  arms  are  involved,  with 
the  consequent  deformities.  Vasomotor  changes  are  observed  in 
this  type. 

Rarely  all  the  types  are  more  or  less  blended  in  the  same  indi- 
vidual. Usually,  the  electro-contractility  is  preserved  so  long  as 
muscular  fibers  remain. 

Diagnosis. — When  wasting  palsy  is  fully  developed,  its  diagnosis 


586  PSEUDO-HYPERTEOPHIC  MUSCULAE   PAEALYSIS 

is  a  simple  matter.  In  its  early  stages  a  doubt  may  exist,  but  atten- 
tion to  the  history,  symptoms,  and  progress  will  determine  the 
question. 

Syringomyelia  often  begins  with  a  muscular  atrophy  as  a  marked 
symptom,  and  may  be  confounded  with  wasting  palsy,  the  chief 
points  of  distinction  between  which  are :  the  loss  of  power  of  perceiving 
heat,  or  often  to  distinguish  between  heat  and  cold,  and  the  appear- 
ance of  trophic  changes,  such  as  a  dusky  or  purplish  hue  of  the  hands, 
with  a  uniform  thickness  resembling  myicedema,  the  development 
of  blebs  and  ulcers,  changes  in  the  nails,  and  sometimes  arthropathies 
in  the  former. 

Prognosis. — Very  unfavorable,  although  the  danger  to  life  is  often 
very  remote.  The  disease  may  be  arrested  and  remain  stationary 
for  years. 

Treatment. — Internal  medication  seems  to  have  little  or  no  effect 
on  the  malady.  In  syphilitic  cases,  mercury  and  potassium  iodide 
should  be  administered  and  if  mineral  poisoning  is  suspected  potas- 
sium iodide  alone  should  be  given.  A  generous  diet  together  with 
the  administration  of  drugs  such  as  arsenic,  strychnine  sulphate, 
and  cod-liver  oil  is  indicated  in  all  cases.  If  the  disease  is  the  result 
of  overexertion  of  any  group  or  groups  of  muscles,  these  groups  should 
be  placed  at  absolute  rest.  Galvanism  applied  locally  to  the  affected 
muscles  is  of  great  benefit.  Faradism  is  also  of  value.  Massage, 
friction,  and  hot  sponging  are  useful  adjuvants  to  the  treatment. 

PSEUDO-HYPERTROPHIC  MUSCULAR  PARALYSIS 

Synonyms. — Pseudo-muscular  hypertrophy;  lipomatous  muscular 
atrophy. 

Definition. — A  diseased  condition  of  the  muscles  in  which  the  muscle- 
fibers  undergo  atrophy  and  are  replaced  by  adipose  and  connective 
tissue,  causing  weakness  and  enlargement  of  the  muscles. 

Causes. — The  condition  is  first  noticed  in  childhood  and  is  markedly 
influenced  by  heredity.  Certain  families  seem  especially  predisposed. 
Boys  seem  more  liable  to  be  affected  than  girls. 

Pathology. — Except  in  very  rare  instances  the  structural  changes 
are  confined  to  the  affected  muscles.  Microscopic  examination 
reveals  atrophy  of  the  individual  muscle-fibers  with  the  disposition 
of  adipose  and  connective  tissue  between  them. 

Symptoms. — Weakness   of   the   muscles   with   awkwardness   and 


SPINAL   SCLEROSIS  587 

clumsiness  in  performance  of  ordinary  movements  such  as  walking, 
is  the  earliest  symptom.  This  progresses  and  paralysis  of  the 
extremities  with  muscular  enlargement  is  soon  manifest.  On  rising 
from  a  recumbent  posture  the  patient  gets  up  on  all-fours,  raising 
the  trunk  by  moving  the  hands  upon  the  floor,  eventually  becoming 
erect  by  pushing  himself  up  by  his  hands  on  the  knees.  The  gait 
is  waddling.  Electric  excitability  is  diminished  but  the  reactions 
of  degeneration  are  never  obtained.  Reflexes  are  lessened  and  some- 
times absent.  Disturbances  of  sensation  and  mental  disorders  are 
absent.  As  the  disease  progresses,  the  patient  ultimately  becomes 
bed-ridden  although  apparently  well  preserved  for  a  long  period. 
The  course  is  indefinite  and  the  outlook  is  unfavorable.  Death 
usually  results  from  some  intercurrent  affection.  Treatment  is  of  no 
avail. 

ACUTE  ASCENDING  PARALYSIS 

Synonym. — Landry's  paralysis. 

Definition. — An  acute  disease  characterized  by  palsy  beginning 
in  the  feet  and  ascending  to  other  muscles  of  the  body,  finally  involving 
the  medulla.  Pain  and  trophic  disturbances  are  absent.  The  re- 
flexes are  diminished  or  absent,  but  the  muscles  do  not  waste,  and 
the  sphincters  are  not  involved.  The  affection  is  rare  and  occurs 
most  often  in  young  male  adults.  The  etiology  and  pathology 
are  obscure ;  it  is  said  to  be  due  to  a  toxin  which  causes  degeneration 
in  the  anterior  horn  of  the  spinal  cord.  The  onset  is  sudden  and  the 
course  acute,  terminating  usually  in  death  within  a  week,  occasionally 
being  prolonged  three  or  four  weeks .  The  treatment  is  unsatisfactory ; 
that  recommended  for  myelitis  or  for  multiple  neuritis  may  be  tried. 

SPINAL  SCLEROSIS 

Definition. — A  myelitis;  an  increase  in  the  connective  tissue  of 
the  spinal  cord,  with  atrophy  of  the  nerve-structure  proper. 

Varieties. — 1.  Lateral  sclerosis.  II.  Posterior  sclerosis,  or  locomotor 
ataxia.     111.  Ataxic  paraplegia.     lY.  Cerebrospinal  sclerosis. 

Causes. — Generally  there  is  an  hereditary  neuropathic  predis- 
position. The  affection  occurs  most  often  in  males  between  the 
ages  of  thirty -five  and  fifty-five.  Among  the  principal  etiological 
factors  may  be  mentioned  syphilis,  alcoholism,  mineral  poisons, 
shock  or  injuries  to  the  cord,  overexertion,  and  exposure  to  cold  and 


588  AMYOTEOPHIC   LATERAL   SCLEROSIS 

wet.  It  is  said  that  railroad  enginemen  and  firemen,  as  well  as 
conductors  and  other  trainmen,  suffer  from  this  and  other  spinal 
diseases  by  reason  of  the  continual  concussion  of  railway  travel.  The 
freedom  from  the  disease  in  the  negro  has  been  noted  by  Mitchell. 
Pathological  Anatomy. — The  changes  in  the  cord  are  gradual  in 
their  development  and  follow  a  longitudinal  instead  of  a  transverse 
direction.  The  form,  consistency,  and  color  of  the  cord  are  altered, 
it  being  atrophied,  indurated,  and  of  a  grayish  color.  The  changes 
-  are  hyperplasia  of  the  connective  tissue,  with  granular  degeneration, 
atrophy  and  disappearance  of  the  nerve-elements  proper.  The 
nerve-roots  undergo  the  same  fibroid  change.  The  joints  undergo 
remarkable  atrophic  degeneration — the  arthropathies  or  Charcot 
joints,  consisting  of  an  osseous  hyperplasia,  the  joint  enlarging  to  an 
enormous  extent. 

AMYOTROPHIC  LATERAL  SCLEROSIS 

Synonyms. — Anterolateral  sclerosis;  spasmodic  tabes  dorsalis 
(Charcot);  spastic  spinal  paralysis  (Erb);  primary  lateral  sclerosis. 

Definition. — ^A  degeneration  of  the  lateral  columns  of  the  cord, 
characterized  by  paraplegia,  contractures  of  the  muscles,  with 
exaggerated  reflexes. 

Pathology. — The  exact  morbid  condition  is  still  a  subject  of  dis- 
cussion. The  site  of  the  lesion  is  the  lateral  white  columns,  in  some 
cases  extending  to  the  anterior  horn,  and  involving  the  whole  length 
of  the  cord.  The  changes  consist  in  an  interstitial  hyperplasia  of 
the  connective  tissue,  and  an  atrophy  of  the  nerve-elements. 

Symptoms. — The  onset  of  the  disease  is  very  gradual,  with  in- 
creasing feeling  of  heaviness  and  weakness  in  the  limbs,  progressing 
to  a  complete  paraplegia.  There  are  also  jerking  and  twitching 
with  cramps  and  stiffness  of  the  muscles  of  the  paretic  limbs.  The 
spasms  of  the  legs  gradually  increase  in  extent  as  the  power  lessens, 
until  at  last  the  legs,  whenever  extended,  pass  into  a  condition  of  strong 
extensor  spasm,  rigidly  fixing  them  to  the  pelvis,  so  that  the  patient 
lies  rigid;  if  one  leg  is  lifted  from  the  couch  by  the  observer,  the  other 
leg  is  moved  also.  The  spasm  may  be  such  that  the  knee  cannot  be 
passively  flexed  by  any  force  that  can  be  applied  to  it,  until  the 
spasm  has  lessened.  When  flexed,  the  limb  is  comparatively  supple; 
but^^if^it  is  then  extended,  the  spasm  instantly  returns,  making  the 
limb  rigid  and  often  completing  the  extension,  just  as  the  blade  of 


LOCOMOTOR   ATAXIA  589 

a  knife  opens  out  under  the  influence  of  its  spring,  "clasp-knife  rigid- 
ity." Occasionally  there  occur  brief  flexor  spasms,  drawing  the  legs 
up.  The  knee-jerk  is  greatly  exaggerated,  and  there  can  also  be 
developed  rectus  clonus  and  ankle  clonus.  Electro-contractility 
is  imparied  early  and  gradually  declines  until  abolished. 

Seguin  called  attention  to  a  "desire  to  micturate  that  is  far  less 
controllable  than  it  should  be  in  a  healthy  person." 

The  spastic  gait  is  characteristic,  termed  by  Hammond  "the 
waddle;"  the  legs  drag  behind  and  are  moved  forward  as  a  rigid 
whole,  the  toes  catching  against  the  ground,  the  patient  showing 
a  tendency  to  fall  forward. 

Sensation  is  unaffected.  As  the  morbid  process  extends  upward, 
the  superior  extremities  suffer  in  the  same  manner  as  the  lower. 

Diagnosis. — The  gradual  development  of  weakness  in  the  legs, 
excess  of  myotatic  irritability,  and  spasms  with  developing  spastic 
gait  render  the  diagnosis  clear.  If  the  symptoms  develop  suddenly 
or  acutely,  the  morbid  condition  is  not  of  the  degenerative  variety. 

Prognosis. — Complete  recovery  is  rare.  If  the  condition  is  early 
recognized,  its  progress  may  be  held  in  check  for  a  long  time. 

Treatment. — Rest  is  of  great  importance  and  every  means  should 
be  taken  to  improve  the  general  health.  Massage  and  warm  baths 
are  of  value.  When  the  affection  can  be  attributed  to  syphilis  or 
mineral  poisoning,  increasing  doses  of  potassium  iodide  or  gold  and 
sodium  chloride  should  be  administered.  Silver  nitrate  or  silver 
oxide  often  retards  the  hyperplasia  of  connective  tissue.  Benefit 
may  sometimes  follow  the  use  of  a  weak  galvanic  current  but  as  a 
rule  electricity  is  disappointing  in  central  diseases. 

LOCOMOTOR  ATAXIA 

Synonyms. — Tabes  dorsalis;  posterior  spinal  sclerosis. 

Definition. — A  chronic  degeneration  of  the  posterior  columns  of 
the  spinal  cord  and  the  posterior  nerve-roots,  characterized  by  loss 
of  coordination,  neuralgic  pains  in  the  limbs,  loss  of  sensation  and 
reflexes,  and  visceral  and  trophic  changes. 

Causes. — The  disease  usually  attacks  males  between  the  ages  of 
twenty  and  fifty,  one-half  of  the  cases  occurring  between  thirty  and 
forty  years  of  life.  The  most  potent  etiological  factor  appears 
to  be  syphilis,  although  alcoholism,  exposure,  traumatism,  etc.,  may 
be  considered  as  contributory  factors. 


590  LOCOMOTOR   ATAXIA 

Pathology. — It  may  be  considered  as  a  general  disease  of  the 
nervous  system  affecting  both  central  and  peripheral  portions  though 
mainly  limited  to  sensory  or  afferent  structures  (Peterson).  It  is 
also  described  as  a  progressive  destructive  process  which  has  a 
selective  influence  on  certain  tracts  in  the  posterior  columns  with 
their  roots' and  ganglia  and  to  a  less  extent  on  the  peripheral  nerves, 
'particularly  the  optic  and  oculo-motor.  The  nerve-fibers  of  the 
cord  are  first  involved.  Their  destruction  is  not  a  simple  wasting, 
but  is  accompanied  with  evidence  of  irritation,  such  as  swelling  of 
axis  cylinders,  and  secondarily,  proliferation  of  connective  tissue  and 
slight  congestion  (Dana). 

The  degenerated  portions  of  the  cord  appear  grayish  or  slightly 
pinkish  and  translucent,  and  somewhat  depressed.  The  pia  is 
slightly  thickened  and  may  be  turbid.  Microscopically,  the  disease 
begins  on  either  side  in  the  posterior  nerve-root  and  extends  into  the 
postero-external  columns  of  Burdach  while  at  higher  levels  the  postero- 
internal columns  of  Goll  are  also  involved.  The  posterior  vesicular 
columns  of  Clarke,  the  marginal  zone  of  Lissauer,  and  the  medullary 
bridge  of  Weigert  may  at  times  be  affected.  The  morbid  process 
usually  begins  and  is  most  marked  in  the  dorso-lumbar  segment  of 
the  cord. 

Symptoms. — Locomotor  ataxia  may  be  divided  into  three  periods : 
I,  disturbances  of  sensation;  2,  loss  of  coordinating  power;  3, 
paralysis. 

The  onset  of  the  disease  is  gradual,  characterized  by  sharp,  darting, 
electric-like  pains  in  the  lower  limbs,  with  disorders  of  the  gastroin- 
testinal and  genitourinary  tracts.  Associated  with  the  pains  is  a  loss 
of  sensation  in  the  feet,  the  patient  being  unable  to  distinguish  be- 
tween hard  and  soft  substances  in  walking,  and,  if  the  upper  portion 
of  the  spinal  cord  be  affected,  is  unable  to  coordinate  the  muscles  of 
the  fingers  sufficiently  to  button  his  clothing.  The  sensation  of  formi- 
cation over  the  surface,  especially  over  the  lower  limbs,  and  about  the 
waist,  the  knee,  and  the  ankle,  is  present;  there  is  nearly  always  a 
feeling  of  constriction  about  the  trunk — the  girdle  sensation. 

Loss  of  coordination,  or  ataxia,  is  manifested  by  the  subject  being 
unable  to  walk  upon  a  straight  line  with  his  eyes  closed,  and  with 
difficulty  if  his  eyes  are  opened.  There  is  inability  to  preserve  the 
erect  position  with  the  feet  close  together,  the  body  swaying  widely 
and  the  patient  falling  on  attempting  to  stand  with  closed  eyes — 
Romberg's   symptom;   and  as  the   malady  progresses  the  patient 


LOCOMOTOR   ATAXIA  59 1 

throws  his  feet  and  legs  in  the  most  grotesque  manner  when  walking. 
Although  the  patient  is  unable  to  coordinate  the  muscles,  their  power 
is  not  lost,  for,  on  being  supported,  he  can  kick  or  strike  with  his  usual 
force.  The  sight  is  early  impaired,  due  to  atrophy  of  the  optic  nerve, 
causing  either  double  vision  or  inability  to  distinguish  between  differ- 
ent colors.  Very  early  there  is  loss  of  pupil-reflex  to  light,  the  reac- 
tion to  accommodation  being  preserved — Argyll-Robertson  symptom. 
Ocular  palsies  may  also  occur.  As  the  disease  progresses,  sensation 
becomes  more  and  more  blunted  and  pain  is  slowly  recognized,  fre- 
quently several  minutes  elapsing  before  the  pricking  of  a  pin  is  appre- 
ciated. A  characteristic  sign  of  the  disease  is  the  abolition  of  the 
patellar  tendon-reflex — Westphal's  symptom — as  well  as  other  re- 
flexes in  the  lower  limbs.  Loss  of  the  sensation  of  temperature  also 
occurs.  The  electro-contractility  is  decreased  in  the  affected  limb. 
General  emaciation  is  marked. 

Vasomotor  and  trophic  symptoms,  more  or  less  pronounced,  occur 
in  all  cases.  "Perforating  ulcers"  of  the  feet,  circumscribed  loss  of 
hair,  changes  in  the  nails,  and  local  sweatings  are  the  more 
common.  Muscular  atrophy,  either  localized  or  general,  is  not 
infrequent. 

Fraenkel,  under  the  term  "hypotonia,"  describes  a  condition  found 
in  tabetic  persons  in  which  the  patient,  lying  on  a  flat  surface,  can 
completely  straighten  his  legs  when  at  right  angles  to  the  body,  which 
cannot  be  done  by  a  normal  man,  whose  knees  will  be  bent  when  the 
thighs  are  at  right  angles  with  the  body. 

Either  early  or  late  in  the  disease,  occur  disturbances  in  micturition 
and  loss  of  sexual  power  and  often  desire.  There  also  occur,  in  a  fair 
number  of  cases,  painless  swelling  and  disintegration  of  various  joints, 
particularly  the  knee  and  elbow — the  tabetic  arthropathies,  or  Charcot 
joints. 

At  any  period  of  the  disease,  peculiar  crises  or  neuralgic  attacks 
occur;  if  griping  pains  in  stomach  with  vomiting,  gastric  crises;  if  renal 
pain  or  colic  with  disturbed  urinary  flow,  nephritic  crises;  if  pain  in 
bladder,  vesical  crises;  if  pain  in  rectum  with  hemorrhoids,  rectal 
crises;  if  severe  paroxysm  of  coughing,  bronchial  crises;  if  constriction 
of  the  throat  with  dyspnea,  laryngeal  crises;  if  cardiac  pain  and  tachy- 
cardia, cardiac  crises. 

Paralysis  finally  ends  the  suffering  of  the  patient.  There  is  gener- 
ally an  entire  absence  of  cerebral  phenomena,  although  rarely  delu- 
sions or  dementia  develop  toward  the  end  of  the  malady. 


592  LOCOMOTOR   ATAXIA 

Diagnosis. — There  are  four  pathognomonic  symptoms  of  loco- 
motor ataxia,  the  presence  of  which  makes  the  diagnosis  positive; 
they  are  Westphal's  symptom — absence  of  patellar  reflex;  Romberg's 
symptom — swaying  of  body  and  inability  to  maintain  erect  position 
with  closed  eyes;  the  Argyll-Robertson  symptom — loss  of  pupil 
reflex  to  light,  but  reaction  to  accommodation  retained;  Frsenkel's 
symptom — hypotonia. 

Chronic  myelitis  is  characterized  by  paralysis,  and  the  course  of  the 
affection  is  otherwise  so  different,  that  an  error  should  be  impossible. 

Disease  of  the  cerebellum  presents  symptoms  of  disordered  coordina- 
tion, but  they  are  the  result  of  vertigo,  and  are  associated  with  head- 
ache, nausea,  and  vomiting,  with  absence  of  neuralgic  pains  and  eye 
symptoms. 

Paraplegia  is  a  true  paralysis,  while  locomotor  ataxia  is  not.  Neu- 
ralgic pain  is  not  a  symptom  of  paraplegia. 

Gastralgia  may  simulate  the  gastric  crises  of  locomotor  ataxia,  but 
the  history  and  attendant  phenomena  will  serve  to  make  a  distinction. 

Multiple  neuritis  shows  loss  of  power  with  pain  and  tenderness  but 
does  not  present  the  four  pathognomonic  symptoms  mentioned  above. 

Prognosis. — The  outlook  is  unfavorable.  The  disease  runs  a 
chronic  and  progressive  course  extending  over  several  years  with 
occasional  remissions.  Stationary  periods  may  be  encountered.  In 
the  early  stages  the  progress  may  be  retarded  by  treatment.  The 
affection  ultimately  ends  in  death  by  some  intercurrent  disease. 

Treatment. — Absolute  rest,  preferably  in  bed,  over  an  extended 
period  is  essential  to  the  proper  management  of  each  case.  Excite- 
ment, mental  exertion,  and  sexual  excesses  should  be  avoided.  Meas- 
ures should  be  taken  to  improve  the  general  health  independently  of 
the  nervous  condition.  For  this  purpose  nutritious  food,  cod-liver 
oil,  hypophosphites,  strychnine,  etc.,  are  indicated.  The  association 
of  syphilis  with  this  affection  calls  for  the  administration  of  potassium 
iodide  and  the  bichloride  of  mercury  in  full  doses.  The  chloride  of 
gold  and  sodium,  gr.  }4q  (0.003  g^-)>  three  times  daily,  often  serves  to 
retard  the  progress  of  the  disease.  The  best  medicinal  results  are 
obtained  from  the  use  of  silver  nitrate,  gr.  >^  to  y^  (0.016  to  0.03  gm.), 
or  silver  oxide,  gr.  I'i  (0.03  gm.),  three  times  daily,  withholding  the 
drug  at  intervals  of  a  few  weeks  to  prevent  discoloration  of  the  skin 
(argyria). 

Massage  and  systematic  exercise  are  of  great  value.  The  system 
of  Frsenkel  in  which  the  patient  is  made  to  re-learn  coordination  and 


ATAXIC  PARAPLEGIA  593 

practise  the  same,  from  the  most  simple  to  the  most  complex  move- 
ments, is  undoubtedly  productive  of  great  benefit.  Many  modifica- 
tions of  this  system  are  in  vogue  all  of  which  are  adapted  to  individual 
cases  and  differ  little,  if  any,  in  principle.  The  employment  of  cold 
along  the  spine  in  the  form  of  cold  sponging,  cold  spinal  pack,  or  short 
application  of  the  cold  douche  is  of  value.  The  application  of  the 
galvanic  continuous  current  along  the  spinal  column  with  f  aradism  to 
the  wasting  muscles  is  strongly  advocated. 

In  the  second  stage,  the  suspension  treatment  of  Charcot  has 
been  followed  by  temporary  improvement.  It  consists  in  the  sus- 
pension of  the  patient  during  a  period  varying  from  one  to  four 
minutes,  by  means  of  Sayre's  apparatus  for  applying  the  plaster 
jacket  in  spinal  deformities. 

The  pains  require  rest  in  bed  and  the  administration  of  analgesics. 
Counterirritation  over  the  nerve-root  supplying  the  painful  part 
often  relieves  the  distress.  Massage  and  the  alternate  hot  and  cold 
douche  are  sometimes  of  benefit.  The  actual  cautery  applied  to  the 
back  once  a  month  is  said  to  relieve  the  pains.  The  faradic  brush, 
static  spark,  and  anodal  application  of  the  galvanic  current  may  be 
of  value.  Resort  to  opium  or  one  of  its  derivatives,  however,  is 
nearly  always  necessary. 

The  various  other  symptoms  should  be  treated  on  general  thera- 
peutic principles  as  they  arise.  When  there  is  increased  arterial 
tension  nitroglycerin  should  be  used,  but  its  use  must  be  guarded 
when  aortic  insufficiency  is  present.  Cannabis  indica  is  sometimes 
of  value. 

ATAXIC  PARAPLEGIA 

Synonym. — Combined  lateral  and  posterior  sclerosis. 

Definition. — A  chronic  degeneration  of  the  lateral  pyramidal 
tracts  and  of  the  posterior  columns  of  the  spinal  cord,  characterized 
by  gradually  developing  paraplegia,  with  ataxia  and  spasms  of  the 
limbs. 

Causes. — The  causes  are  not  so  well  determined  as  in  other  varie- 
ties of  spinal  sclerosis. 

Pathology. — A  sclerosis  of  the  lateral  and  posterior  columns  of 
the  spinal  cord  is  a  constant  structural  change.  It  is  to  be  noted 
that  the  posterior  columns  show  the  morbid  changes  higher  up  than 
in  locomotor  ataxia — the  dorsal  rather  than  the  lumbar  regions — and 
that  the  root-zone  of  the  postero-extemal  column  is  much  less  in- 
38 


594  CEREBROSPINAL   SCLEROSIS 

volved.  Nor  do  the  lateral  tracts  show  the  same  degree  of  involve- 
ment as  in  spastic  paraplegia. 

Symptoms. — The  onset  is  slow  and  gradual,  with  loss  of  power 
in  the  lower  extremities.  The  muscles  involved  are  particularly 
the  flexors  of  the  thigh  and  knee.  One  leg  may  be  weaker  than  the 
other.  There  is  also  ataxia,  the  patient  being  unsteady  when  stand- 
ing with  feet  together  (tabetic  swaying),  and  he  tends  to  fall  if  the 
eyes  are  at  the  same  time  closed.  Spasms  of  the  lower  extremity 
gradually  develop  and  finally  become  as  marked  as  in  spastic  para- 
plegia. The  knee-jerk  reflex  is  increased,  quick  and  extensive,  and 
rectus  and  ankle  clonus  can  be  developed.  The  sexual  power  is 
lost  early.  Incontinence  of  urine  is  frequent.  Sensation  is  unim- 
paired, and  neuralgic  pains  are  absent,  as  are  also  eye  symptoms. 

Diagnosis. — The  conditions  ataxic  paraplegia  is  most  liable  to 
be  mistaken  for  are  locomotor  ataxia  and  spastic  paraplegia.  The 
presence  of  knee-jerk  and  loss  of  power  in  lower  extremities  are  of 
value  in  discriminating  from  locomotor  ataxia.  Spastic  paraplegia 
is  not  associated  with  ataxia — indeed,  ataxic  paraplegia  is  spastic 
paraplegia  plus  incoordination. 

Prognosis. — Unfavorable.     The  condition  is  progressive. 

Treatment. — The  same  plan  of  treatment  may  be  tried  as  rec- 
ommended for  lateral  or  posterior  sclerosis. 

CEREBROSPINAL  SCLEROSIS 

Synonyms. — Multiple  sclerosis  of  the  brain  and  cord;  cerebral 
sclerosis;  spinal  sclerosis;  disseminated  sclerosis  (Charcot);  insular 
sclerosis. 

Definition. — A  degenerative  disease  of  the  brain  and  spinal  cord, 
characterized  by  pains  in  the  back,  disorders  of  sensation,  loss  of 
coordination,  tremor  on  motion,  scanning  speech,  and  some  mental 
impairment. 

Pathology. — The  disease  consists  in  the  development  of  patches 
of  grayish,  translucent,  tough  nodules,  varying  in  size  from  a  micro- 
scopic object  up  to  the  size  of  a  walnut,  varying  in  number  and  widely 
distributed  in  the  white  matter  of  the  hemispheres,  ventricles,  optic 
thalamus,  corpus  striatum,  peduncles,  pons,  and  cerebellum,  while 
in  the  cord  they  are  found  in  both  the  white  and  gray  matter  and  in 
the  columns.  The  deposits  are  also  found  in  the  nerve-roots  and 
nerve-trunks.  The  nodules  are  composed  of  the  neuroglia,  much 
altered,  and  a  newly  formed  connective  tissue.     The  result  of  the 


CEREBROSPINAL   SCLEROSIS  595 

growth  of  the  nodules  is  pressure  upon  the  nerve-structure  ending  in 
its  degeneration. 

Symptoms. — The  affection  may  be  considered  as  of  three  varie- 
ties, depending  upon  the  site  of  the  most  marked  changes;  cere- 
bral, spinal,  or  mixed.  The  latter  variety  is  the  more  common.  It 
is  observed  in  younger  individuals  than  are  the  other  forms  of  sclerosis. 

The  onset  is  usually  insidious  and  is  attended  by  more  or  less 
severe  pains  in  the  limbs  and  back,  which  the  patient  attributes  to 
rheumatism,  and  a  sensation  of  formication,  itching  and  burning  in 
the  limbs.  Very  rarely,  the  malady  is  ushered  in  with  apoplecti- 
form symptoms.  Loss  of  coordination  of  the  hands  in  writing,  or  of 
the  feet  in  walking,  soon  becomes  manifest,  followed  after  a  time  by 
paresis,  more  or  less  general,  with  contracture  of  the  muscles.  Vol- 
untary movements  of  the  paretic  limbs  develop  a  tremor  which  sub- 
sides when  the  limbs  are  at  rest — intentional  tremor.  It  is  increased 
by  excitement.  It  extends  to  the  head  and  neck  causing  shaking  of 
the  head  on  raising  it  from  a  pillow,  or  a  similar  movement.  An  early 
and  frequent  symptom  is  nystagmus.  The  loss  of  coordination,  with 
tremor  and  with  contractures  of  the  muscles  of  the  legs,  gives  rise  to 
the  ''waddle"  or  "hop  gait"  when  walking.  The  speech  is  slow, 
scanning,  or  slurring  in  character.  There  are  also  present  headache, 
vertigo,  and  mental  impairment,  together  with  an  unnatural  content- 
ment of  the  feelings  and  with  the  surroundings.  Disorders  of  vision 
from  optic  atrophy  and  disturbances  of  hearing  may  occur.  Sexual 
impairment,  vesical  disorders,  gastric  and  other  crises,  and  bed-sores 
may  also  be  symptoms  of  this  condition.  The  knee-jerk  and  wrist- 
jerk  are  exaggerated  and  ankle  clonus  is  present.  The  disease  is 
progressive,  the  symptoms  developing  as  the  various  nerve-tracts 
are  invaded.     Trophic  disturbances  are  seldom  present. 

The  duration  of  the  disease  ranges  from  one  to  twenty  years,  the 
average  being  five  to  ten  years.  During  this  period  the  patient  is 
very  liable  to  develop  pulmonary  tuberculosis  or  chronic  nephritis. 

Diagnosis. — The  following  group  of  symptoms,  characteristic  of 
this  disease,  should  prevent  any  error  in  diagnosis;  pains  in  the  limbs 
and  back,  loss  of  coordination  in  the  feet  and  hands,  muscular  weak- 
ness with  contractures,  intentional  tremor,  nystagmus,  scanning 
speech,  disordered  vision,  increased  reflexes,  and  vertigo. 

Paralysis  agitans  may  be  mistaken  for  disseminated  sclerosis.  The 
chief  points  in  the  diagnosis  are  the  presence  in  paralysis  agitans  of 
the  fine  tremor  continually  without  shaking  of  the  head,  with  a  pecul- 


596  HEEEDITARY  ATAXIA 

iar  flexion  and  rigidity  of  the  hand,  while  in  cerebrospinal  sclerosis  the 
tremor  is  produced  only  on  movement  of  the  muscle,  and  is  associated 
with  shaking  of  the  head.  Paralysis  agitans  is  a  disease  of  middle 
life,  sclerosis  occurs  under  forty  years.  Changes  in  the  voice, 
speech,  and  vision  are  present  in  cerebrospinal  sclerosis,  but  absent  in 
paralysis  agitans.  . 

Tumor  of  the  pons  or  cms  is  accompanied  by  wild,  jerky  incoordina- 
tion closely  resembling  disseminated  sclerosis,  but  tumor  also  has 
headache,  vomiting,  optic  neuritis,  local  spasm,  and  local  paralysis. 

General  paralysis  of  the  insane  and  disseminated  sclerosis  are  fre- 
quently confounded,  as  are  locomotor  ataxia  and  primary  lateral 
sclerosis.  A  careful  consideration  of  the  characteristic  symptoms, 
already  mentioned,  will  serve  to  make  a  distinction. 

Prognosis. — Unfavorable.  The  disease  slowly  but  steadily  pro- 
gresses, chronic  nephritis  or  tuberculosis  frequently  developing  and 
causing  death. 

Treatment. — There  is  no  drug  having  the  power  to  cure  sclerosis. 
Syphilis  is  the  cause  of  the  majority  of  the  cases,  and  potassium  iodide, 
in  large  doses,  may  sometimes  hold  the  disease  in  check  for  a  time. 

Attention  to  the  general  health  and  remedies  to  promote  con- 
structive metamorphosis  will  prolong  life  and  add  to  the  comfort  of 
the  individual.  Massage,  hydrotherapy,  electricity,  and  systematic 
exercises  may  be  of  benefit  and  should  be  given  a  fair  trial. 

HEREDITARY  ATAXIA 

Synon5nns. — Friedreich's  disease;  hereditary  ataxic  paraplegia. 

Definition. — A  sclerosing  disease  of  the  lateral  and  posterior  col- 
umns of  the  spinal  cord  which  shows  a  predilection  for  certain  fami- 
lies and  occurs  at  an  earlier  age  than  locomotor  ataxia. 

Causes. — The  etiology  is  obscure.  The  affection  occurs  in  a  num- 
ber of  the  members  of  the  same  family  and  manifests  itself  between  the 
ages  of  two  and  twenty-four. 

Symptoms. — The  essential  features  of  this  disease  are  ataxia  and 
paraplegia.  Pains  are  seldom  present.  Irregular  jerky  movements 
of  the  head,  impaired  speech,  disordered  vision,  loss  of  muscular 
power,  and  diminished  reflexes  are  common.  Sensory  phenomena 
are  seldom  marked  and  trophic  disturbances  are  unusual.  Deformi- 
ties of  the  feet  and  lateral  spinal  curvatures  are  not  infrequent. 

Treatment. — The  treatment  is  unsatisfactory.  The  disease  tends 
to  progress,  although  the  course  may  be  extremely  slow  and  extend 


SYRINGOMYELIA 


597 


over  several  years.     The  measures  recommended  in  locomotor  ataxia 
are  applicable  to  this  affection. 


Dififerential  Diagnosis  of  Chronic  Diseases  of  the  Spinal   Cord 

From  Wheeler  and  Jack's  Handbook  of  Medicine 
Table  I 


Locomotor  ataxia 


Ataxic  paraplegia 


Friedreich's  ataxia 


Age 

Causes. 


Ocular 

toms. 


symp- 


[  Argyll- Rob  ert- 
I    son  pupil. 
\  Nystagmus. .  . 
Tendon    reflexes 

(knee-jerk). 
Disorders  of  sen,- 

sation. 


Incoordination. . 


Speech. 


Middle-aged  men.  . 

The  toxic  effects  of 
syphilis,  rarely 
other  toxins. 

Various  muscular 
paralyses  or  pal- 
sies. 

Present 

Absent 

Lost 

Lightning  pains 

prominent;  girdle 
sensation:  numb- 
ness of  feet. 

Characteristic  gait; 
lower  limbs  chiefly 
affected,  upper 
limbs  later. 

Unaffected 


Early  middle    life; 

males. 
Exposure       to       cold, 

traumatisms,  etc. 


Absent. . . 

Absent. . . 
Increased 

Absent. . . 


Ataxia    marked 
spasm     and     rigidity 
also       present,       and 
tend  to  increase. 

Seldom  affected 


Childhood  or  early 
youth. 

Occurs  in  many  of  the 
same  generation. 
Neurotic  predisposi- 
tion. 


Absent. 

Present. 
Lost. 

Absent    usually;    occa- 
sional paresthesiae. 


Marked,  but  irregular 
and  jerky;  may  affect 
upper  limbs. 

Often  affected. 


Table  II 


Progressive 
muscular  atrophy 


Amyotrophic 
paralysis 


Primary  spastic 

paraplegia     (lateral 

sclerosis) 


Limbs  most 

affected. 


Deformity. 


Tendon    reflexes 

(knee). 
Electrical 

changes. 


Upper  — y  atrophy 
begins  in  thenar 
and  hypothenar 
eminences.  Uni- 
lateral at  first. 

The  "claw-like" 
hand. 


Unaffected. 


Reaction  of  degen 
eration  sometimes 
present. 


Upper  —  _  atrophy 
may  begin  in  muscles 
of  forearm  or  deltoid. 
Unilateral. 

Flexion  of  elbow,  pro- 
nation of  hand,  flex- 
ion of  wrists,  and 
fingers  into  palms. 

Unaffected 

Partial  R.  D.  or  di- 
minished  excitability. 


Lower — no  atrophy, 
but  rigidity  and 
spasm  are  present. 
Bilateral. 

Adduction  of  legs. 
They  may  cross  each 
other. 


Exaggerated    on 
sides. 
Normal  as  a  rule. 


both 


SYRINGOMYELIA 


Synonym. — Syringomyelitis. 

Definition. — A  chronic  disease  of  the  spinal  cord,  characterized 


598  SYRINGOMYELIA 

by  the  formation  of  cavities  in  the  substance  of  the  cord,  associated 
with  loss  of  the  perception  of  pain  and  temperature  over  certain 
regions,  and  complicated  with  muscular  weakness  and  atrophy, 
and  at  times  trophic  changes. 

Causes. — The  true  cause  is  unknown.  The  affection  is  rare  and 
occurs  most  often  in  males  between  the  ages  of  ten  and  forty  years. 
Sometimes  it  is  congenital,  and  maybe  associated  with  hydrocephalus. 
Hemorrhage  and  traumatism  of  the  cord  are  believed  to  influence 
its  production  considerably. 

'  Pathological  Anatomy. — There  is  present  a  tubular  cavity  or 
cavities  in  the  substance  of  the  spinal  cord,  the  development  of  which 
is  the  subject  of  considerable  discussion.  It  is  thought  that  these 
cavities  may  originate  either  in  a  faulty  closure  of  one  of  the  divisions 
of  the  primary  central  canal  of  the  cord,  for  in  the  course  of  develop- 
ment the  primary  central  canal  of  the  cord  becomes  divided  into 
two  parts — an  anterior  and  a  posterior.  The  anterior  division 
forms  the  permanent  central  canal.  The  walls  of  the  posterior 
division  gradually  come  together  and  form  the  posterior  fissure. 
The  imperfect  closure  of  either  of  these  divisions  of  the  primary  cen- 
tral canal  may  give  rise  to  syringomyelia.  Or,  the  abnormal  cavity 
or  cavities  may  depend  on  the  disintegration  of  a  gliomatous  forma- 
tion which  originates  generally  in  embryonal  tissue  about  the  central 
canal.  The  cavity  varies  in  extent  and  location  in  different  cases, 
and  it  is  possible  to  find  marked  changes  on  autopsy  which  gave  rise 
to  no  symptoms  during  the  lifetime  of  the  individual.  The  cervical 
cord  is  the  usual  seat  of  the  disease. 

Symptoms. — The  condition  develops  slowly  and  insidiously,  and 
is  nearly  always  bilateral.  There  occur  loss  or  diminution  of  the 
perception  of  temperature  (heat  and  cold)  and  pain,  the  tactile  sense 
being  retained;  and  slowly  developing  muscular  atrophy,  due  to  in- 
volvement of  the  anterior  horns  of  the  cord.  The  atrophy  usually 
affects  the  arm  and  shoulder  of  one  or  both  sides,  and  it  may  begin 
in  the  hand.  Associated  with  the  muscular  atrophy  are  muscular 
weakness  and  more  or  less  fibrillary  contractions.  When  the  weak- 
ness involves  the  spinal  muscles,  scoliosis  follows.  Arthropathies 
occur  in  many  cases,  particularly  involving  the  shoulder-joint. 
Trophic  changes  also  involve  the  skin,  often  advancing  to  ulceration 
and  even  gangrene,  and  rarely  to  painless  felons,  such  as  occur  in 
Morvan's  disease.  The  general  health  of  patients  suffers  but  little 
in  syringomyelia. 


SIMPLE   NEURITIS  599 

The  disease  is  seen  in  many  irregular  types,  the  loss  of  temperature 
sense  in  one  part  and  the  loss  of  sensation  of  pain  in  another,  and  other 
irregular  distribution  of  the  characteristic  phenomena.  The  symp- 
toms of  other  forms  of  spinal  disease,  especially  sclerosis,  may  be 
present  in  addition. 

Diagnosis. — Progressive  muscular  atrophy  is  apt  to  be  confounded 
with  syringomyelia  unless  the  changes  in  the  temperature  and  pain 
senses  are  remembered.  Morvan's  disease  is  by  many  neurologists 
classed  as  a  variety  of  syringomyelia. 

Prognosis. — The  affection  is  incurable,  but  the  duration  is  rather 
long,  extending  over  several  years,  often  with  periods  of  quiescence. 

Treatment. — This  is  unsatisfactory  and  consists  in  measures  for 
the  relief  of  symptoms. 

DISEASES  OF  THE  NERVES 

SIMPLE  NEURITIS 

Definition. — An  inflammation  of  the  nerve-trunks,  characterized 
by  pain,  impaired  sensation,  motor  paralysis,  and  atrophy. 

Causes. — Among  the  principal  causes  may  be  included  wounds, 
injuries,  and  compression  of  the  nerves,  extension  of  adjacent  in- 
flammation, exposure  to  cold  and  wet,  rheumatism,  gout,  infectious 
fevers,  syphilis,  and  lead-poisoning. 

Pathological  Anatomy. — Hyperemia  is  the  earliest  change,  and  is 
soon  followed  by  exudation  into  the  nerve-sheath  and  connective 
tissue  which  becomes  softened  shortly  and  ultimately  breaks  down 
into  a  diffluent  mass.  The  affected  nerve  is  consequently  red  and 
swollen.  The  microscope  shows  that  migration  of  white  corpuscles 
takes  place  into  the  neurilemma  and  that  the  fibers  have  undergone 
more  or  less  granular  change.  Recovery  may  take  place  before  the 
nerve-elements  are  entirely  destroyed  by  absorption  of  the  exudate. 
Inflammation  of  a  nerve  may  extend  upward  (neuritis  ascendens) 
or  downward  {neuritis  descendens).  In  long-standing  cases,  the 
diseased  nerves  are  found  to  be  made  up  largely  of  connective  tissue, 
replacing  the  degenerated  structure. 

Sjrmptoms. — The  onset  may  be  accompanied  by  febrile  reaction. 
The  most  decided  symptom  is  pain  with  tenderness  along  the  course 
of  the  nerve-trunk  and  its  peripheral  distribution,  of  a  burning,  ting- 
ling, tearing,  intense  character,  increased  by  pressure  or  motion. 
If  the  affected  nerve  be  a  mixed  one — sensory  and  motor — spasmodic 


6oo  MULTIPLE   NEUEITIS 

contractions  and  muscular  cramps  occur,  followed  by  impaired 
motion,  terminating  in  paresis  of  the  muscles  innervated  by  the 
affected  trunk.  The  sense  of  touch  and  of  pain  are  markedly  im- 
paired, while  the  temperature  and  muscular  sense  are  but  slightly 
disturbed. 

If  the  inflammation  proceed  to  destruction  of  the  nerve-trunk, 
wasting  and  degeneration  of  the  muscular  tissue  ensue.  Various 
trophic  changes  also  occur,  such  as  cutaneous  eruptions  and  clubbing 
of  the  nails.     The  electro-contractility  is  impaired  or  lost. 

Diagnosis. — Myalgia  or  muscular  pain  is  not  associated  with  paral- 
ysis, nor  does  the  pain  follow  the  course  of  a  nerve-trunk. 

Neuralgia  has  the  pain,  but,  as  a  rule,  not  the  tenderness  of  neuritis. 

Prognosis. — Generally  favorable,  with  proper  treatment. 

Treatment. — The  affected  part  should  be  placed  at  rest.  Repeated 
blistering  along  the  course  of  the  nerve,  preferably  with  the  Paquelin 
cautery,  together  with  the  administration  of  full  doses  of  potassium 
iodide,  is  usually  successful  in  relieving  the  condition.  Sedative 
lotions  will  also  serve  to  lessen  the  pain.  Sodium  salicylate,  phen- 
acetin,  and  antifebrin  may  be  of  value  at  times,  but  in  severe  cases 
morphine,  hypodermically,  is  necessary.  In  syphilitic  cases,  the 
iodides  are  indicated,  and  in  those  due  to  exposure  to  cold  and  wet 
and  rheumatism,  the  salicylates  and  alkalies  are  of  great  value.  In 
all  cases  quinine  sulphate,  gr.  ij  to  v  (0.13  to  0.3  gm.),  every  four 
hours,  should  be  employed  from  the  onset.  As  the  acute  symptoms 
subside,  galvanism  or  a  feeble,  slowly  interrupted  faradic  current 
should  be  used  to  restore  the  functional  activity  of  the  affected  nerve 
and  the  muscles  to  which  it  is  distributed.  Potassium  iodide  and 
strychnine  during  this  period  are  also  of  value.  If  there  are  any  mani- 
festations of  anemia,  iron  together  with  malt  and  the  hypophosphites 
should  be  administered. 

MULTIPLE  NEURITIS 

Synonyms. — Polyneuritis;  peripheral  neuritis;  disseminated  neuri- 
tis; degenerative  neuritis;  pseudo-tabes;  alcoholic  paralysis. 

Definition. — A  parenchymatous  inflammation  of  a  number  of  sym- 
metric peripheral  nerves,  simultaneously  or  in  rapid  succession; 
characterized  by  pain,  numbness,  loss  of  power,  or  ataxia,  with  mus- 
cular atrophy.     Mental  symptoms  are  often  associated. 

Causes. — Multiple  neuritis  arises  from  a  number  of  causes  all  of 
which  are  toxic  in  character  and  possess  a  predilection  for  the  nerve- 


MULTIPLE    NEURITIS  6oi 

fibers.  The  principal  poisons  introduced  from  without  that  may- 
induce  the  affection  are  alcohol,  lead,  arsenic,  silver,  mercury,  phos- 
phorus, anilin,  benzine,  carbon  bisulphide,  and  ergot.  The  internal 
causes  include  the  toxins  of  syphilis,  leprosy,  malaria,  acute  infec- 
tious jaundice,  diabetes,  diphtheria,  typhoid  fever,  septicemia,  small- 
pox, rheumatism,  gout,  chorea,  and  cachectic  states. 

The  affection  occurs  usually  in  adults  between  the  ages  of  twenty 
and  fifty.  It  may  occur  in  children  as  a  complication  of  acute  ante- 
rior poliomyelitis  and  diphtheria.  The  female  sex  is  most  often  at- 
tacked. Emotional  disturbances,  anemia,  and  exposure  to  cold  may 
act  as  exciting  causes.  Alcoholic  multiple  neuritis  is  the  most  com- 
mon form  of  the  disease. 

Pathological  Anatomy. — The  affection  is  generally  bilateral  and 
symmetrical.  An  important  characteristic  is  its  peripheral  distribu- 
tion, the  inflammation  being  most  intense  at  the  extremities  of  the 
nerves,  lessening  progressively  toward  the  center,  usually  terminating 
before  the  nerve-roots  are  reached.  .  The  inflammatory  process  affects 
the  nerve-fibers  primarily  and  the  sheath  and  connective  tissue  sec- 
ondarily— a  parenchymatous  inflammation.  The  affected  muscles 
are  paler  and  smaller  than  normal,  the  fibers  being  reduced  in  size  and 
undergoing  granular  changes. 

Symptoms. — The  onset  may  be  sudden,  even  overwhelming,  caus- 
ing rapid  death,  but  is  usually  subacute  or  chronic  from  the  beginning. 
According  to  the  symptoms,  the  affection  may  be  divided  into  three 
forms,  motor,  sensory,  or  ataxic. 

The  motor  form  manifests  itself  in  motor  weakness,  chiefly  involving 
the  flexors  of  the  ankles,  the  extensors  of  the  toes,  and  the  extensors 
of  the  wrists  and  fingers,  situated  in  the  forearm.  Inflammation  of 
the  anterior  tibial  or  peroneal  nerve  in  the  leg,  and  the  radial  branch 
of  the  musculospiral  in  the  arm  is  common,  resulting  in  the  double 
"foot-drop  "  and  "wrist-drop  "  so  characteristic  of  this  disease.  Any 
of  the  nerves  of  the  body  may  be  affected,  the  motor  symptoms  vary- 
ing with  the  individual  nerves.  Muscular  atrophy  begins  early  and 
progresses  with  the  disease.     The  steppage  gait  is  often  observed. 

The  sensory  form  shows  itself  in  pains,  tenderness,  tingling,  and 
numbness  with  loss  of  cutaneous  sensibility.  At  times  the  hyperes- 
thesia of  the  extremities,  especially  the  soles  of  the  feet  and  the  mus- 
cles, is  so  marked  that  the  slightest  touch  cannot  be  borne. 

The  ataxic  form  is  characterized  by  incoordination  with  or  without 
sensory  disturbances,  but  with  loss  of  muscular  sense. 

These  forms  may  exist  combined  to  a  greater  or  less  extent.     Atro- 


6o2  MULTIPLE    NEURITIS 

phy  of  the  muscles,  feeble  or  absent  knee-jerks,  and  absent  or  dimin- 
ished electro-contractility  are  common  to  all  forms.  Trophic  changes 
may  occur  in  the  nails,  hair,  and  skin.  A  characteristic  glossy  condi- 
tion of  the  skin  with  some  edema  often  results  from  involvement  of 
the  vasomotor  nerves.  Rarely  the  vagus,  optic  nerve,  and  laryngeal 
nerve  are  attacked. 

An  acute  variety  of  the  disease  may  occur,  in  which  the  affection  is 
ushered  in  with  fever,  ioi°  to  io3°F.,  rapid  feeble  pulse,  headache, 
nausea,  vomiting,  and  delirium  or  convulsions  shortly  followed  by 
various  combinations  of  the  motor,  sensory,  and  ataxic  phenomena 
already  described. 

The  chronic  variety  is  unattended  by  febrile  symptonis  and  begins 
insidiously  with  pains  and  other  sensory  disturbances,  followed  by 
weakness  and  wasting  of  the.  muscles,  and  the  other  characteristic 
manifestations  of  this  disease. 

Alcoholic  multiple  neuritis  is  attended  by  several  characteristics 
which  serve  to  distinguish  it.  Foot-drop  is  a  typical  symptom  and 
there  may  be  delirium,  mania,  and  delusions  associated  with  tremors. 
This  variety  usually  affects  all  the  limbs  beginning  in  the  flexors  of  the 
feet,  being  thus  separated  from  the  malarial  form  in  which  the  legs 
are  first  involved;  the  diphtheria  type,  in  which  the  pharyngeal  and 
ocular  muscles  are  first  attacked;  the  rheumatic  in  which  the  muscles 
of  the  face  are  first  affected;  and  the  lead  variety,  which  begins  in  the 
arms  {wrist-drop). 

Diagnosis. — The  distinctive  features  of  this  affection  are  its 
symmetric  distribution,  pain  and  tenderness  over  the  nerve-trunks, 
peripheral  nerves  and  muscles,  the  various  sensory  phenomena,  and 
the  loss  of  power  with  wasting  of  the  muscles,  beginning  in  the 
extremities.  The  history  of  some  toxic  condition  will  also  aid  in 
making  the  diagnosis.  A  careful  consideration  of  these  character- 
istics will  serve  to  differentiate  the  condition  from  other  affections 
with  which  it  might  be  confused.  The  table  from  Chtirch  and 
Peterson  (on  page  603)  is  of  value  in  this  connection. 

Prognosis. — The  outlook  is,  as  a  rule,  favorable,  if  early  and 
proper  treatment  be  instituted.  Involvement  of  the  respiratory 
muscles  in  acute  cases  may  be  the  cause  of  a  fatal  termination. 
In  long-standing  cases,  the  probability  of  restoration  of  the  affected 
muscles  to  normal  is  not  very  great. 

Treatment. — The  primary  cause  should  be  ascertained,  and,  if 
possible,  promptly  removed.  Absolute  rest  in  bed  is  of  great  impor- 
tance.    Pressure  upon  the  affected  parts  should  be  carefully  avoided. 


MULTIPLE    NEURITIS 


603 


Locomotor  Ataxia. 


Girdle  pains  and  lightning  pains  early. 
Nerve-trunks  often  insensitive. 

Muscular  sense  disturbed  early. 

Amyotrophia  and  reaction  of  degen- 
eration absent. 

Peculiarity  of  gait  due  to  incoordina- 
tion and  irrespective  of  muscular 
strength. 

Strikes  heels  first  and  does  not  follow 
straight  line. 

Circulation  and  trophic  condition  of 
limbs  normal. 

Perforating  ulcers,  joint  lesions,  and 
osteopathies  are  common. 

Argyll-Robertson  phenonienon  usual. 

Optic  atrophy  common. 

Vesical  troubles  frequent  and  early. 

Gastric  and  intestinal  crises. 

Fecal  incontinence  common. 

Sometimes  followed  by  paretic  de- 
mentia. 
Of  slow  evolution,  requiring  years. 

Incurable. 

Syphilis  usually  in  the  history. 


Multiple  Neuritis 

No  girdle  pains;  lightning  pains  in- 
frequent. 

Usually  oversensitive  and  often 
thickened. 

Only  slightly  disturbed  or  intact. 

Develop   early. 

Due  to  paresis  and  proportionate  to 
loss  of  power. 

Strikes  toes  and  outer  border  of  foot 
first  and  walks  in  straight  line. 

Edema,  lividity,  and  epithelial 
changes. 

Rare  or  unknown. 

Never  present. 

Rare,  but  toxic  amaurosis  frequent. 

Very  exceptional  and  late. 

Dyspepsias  from  toxic  causes,  consti- 
pation from  lead,  etc. 

Only  in  acute  pernicious  cases  and  in 
stuporous  states. 

Often  accompanied  by  mental  dis- 
turbance. 

Of  insidious,  progressive  develop- 
ment, requiring  months. 

Recovers  if  patient  survives. 

Antecedent  intoxications,  infections, 
and  cachexias. 


The  parts  should  be  wrapped  in  cotton-wool  or  flannel,  and  moist 
or  dry  heat  and  sedative  lotions  or  ointments  should  be  applied. 
Temporary  relief  may  be  afforded  by  change  in  position  of  the  limbs, 
but  unusual  positions  should  not  be  long  maintained  on  account  of 
the  possibility  of  contraction  of  the  muscles  and  subsequent  deformity. 
Antifebrin  and  similar  preparations  may  be  of  benefit  but  in  severe 
cases  morphine,  hypodermically,  is  necessary. 

There  is  no  specific  medication  for  polyneuritis.  In  alcoholic 
cases,  strychnine  nitrate,  should  be  used;  in  malarial  cases,  quinine 
sulphate;  in  diphtheritic  cases,  tincture  of  the  chloride  of  iron  and 
strychnine  sulphate;  in  rheumatic  cases,  sodium  salicylate,  salol,  or 
phenacetin;  in  syphilitic  cases,  mercury  and  potassium  iodide;  and 


6o4  BEEI-BERI 

in  lead  and  other  mineral  poisonings,  the  iodides  should  be  em- 
ployed. In  all  cases,  a  generous  nutritious  diet  with  the  administra- 
tion of  tonics  is  necessary. 

During  convalescence,  moderate  exercise,  massage,  and  mild 
galvanism  should  be  prescribed.  Arsenic  during  this  period  is  con- 
sidered to  be  of  great  value  as  a  constructive  tonic. 

BERI-BERI 

Synonyms. — Kakk6;  endemic  multiple  neuritis. 

Definition. — An  endemic  and  epidemic  form  of  multiple  neuritis, 
occurring  in  tropical  and  subtropical  countries,  and  characterized 
by  motor  and  sensory  paralysis,  anemia,  and  general  edema. 

Etiology. — Unknown.  Two  theories  are  held:  (i)  That  it  is 
an  infection;  but  the  specific  organism  is  not  yet  determined.  (2) 
That  it  is  a  toxemia,  caused  by  food,  either  bad  rice  or  certain  fish. 
Both  theories  may  be  correct.  Contaminated  drinking  water, 
a  nitrogenous  diet,  and  unsanitary  surroundings  are  important 
etiological  factors. 

Pathological  Anatomy. — Peripheral  neuritis,  with  degeneration  of 
the  axis-cylinders,  and  myelin  sheaths ;  the  pneumogastric  and  phrenic 
may  be  attacked  as  well  as  the  peripheral  nerves.  Degeneration  of 
muscle  fibers  in  the  heart  and  voluntary  muscles  may  also  be  found. 

Symptoms. — Incubation  period  a  month  or  more.  The  affection 
is  manifested  by  evidences  of  multiple  neuritis,  cardiac  irritability, 
anasarca,  and  a  generalized  tired  feeling.  In  acute  cases,  there  are 
fever,  anemia,  anasarca,  emaciation,  and  dyspnea.  The  neuritic 
changes  induce  atrophy  and  paralysis  of  the  muscles.  In  severe 
forms  there  may  ensue  paralysis  of  heart  or  larynx  or  diaphragm. 

Prognosis. — The  mortality  ranges  from  3  to  60  per  cent.,  according 
to  the  type  of  the  disease. 

Treatment. — Consists  largely  in  tonic  and  supportive  measures. 
The  salicylates,  in  doses  of  gr.  xv  to  xx  (i.o  to  1.30  gm.),  are  highly 
recommended.  For  the  heart,  digitalis,  or  strychnine  may  be  re- 
quired; as  may  glonoin  if  the  arterial  tension  is  high,  when  gr.  ^00 
(0.0006  gm.)  may  be  given  every  half  hour  until  the  other  remedies 
have  had  time  to  take  effect.  The  diet  and  hygiene  should  receive 
attention. 

HERPES  ZOSTER 

Synonyms. — Zona;  shingles. 

Definition. — An  acute,  inflammatory  disease,  characterized  by 
the  development  of  groups  of  firm  and  distended  vesicles  situated 


HERPES    ZOSTER  605 

upon  inflamed  bases  corresponding  to  a  definite  cutaneous  nerve, 
and  accompanied  by  more  or  less  severe  neuralgic  pains. 

Causes. — The  eruption  and  consequent  neuralgic  pains  are  the 
immediate  result  of  an  inflammation  of  the  posterior  ganglia  of  the 
spinal  nerve-roots;  but  the  cause  producing  this  condition  is  obscure. 
Among  the  many  that  have  been  suggested  are:  cold,  injuries  to  nerve, 
anemia,  malaria,  and  the  medicinal  use  of  arsenic. 

Symptoms. — The  affection  begins  with  neuralgic  pains,  either  of 
a  burning  or  lightning-like  character,  with  slight  febrile  phenomena, 
followed  by  the  appearance  of  papulovesicles  along  the  tract  of  pain ; 
these  soon  become  vesicles  situated  on  bright  red,  highly  inflamed 
bases.  The  vesicles  are  about  the  size  of  pin-heads,  or,  perhaps, 
a  little  larger;  usually  discrete,  although  they  frequently  coalesce, 
forming  irregular  patches,  appearing  in  groups  until  the  third  to  the 
fifth  or  even  tenth  day,  when  they  gradually  desiccate,  and  at  the  end 
of  the  second  week  nothing  remains  except  occasionally  a  slight  scar, 
which  may  disappear  or  become  permanent.  When  the  eruption 
is  at  its  height,  it  is  perfect  in  its  anatomic  formation,  each  vesicle 
being  well  shaped  and  seated  on  a  bright  red,  inflamed  patch  of  skin, 
and  distended  with  a  translucent,  yellowish  fluid.  The  vesicles 
show  no  tendency  to  rupture  spontaneously.  In  rare  instances  they 
may  become  purulent,  hemorrhagic,  or  gangrenous. 

The  eruption  is  almost  invariably  confined  to  one  side  (unilateral) 
of  the  body,  although  in  rare  instances  it  is  seen  upon  both  (bilateral) 
sides.  It  is  usually  found  upon  well-known  nerve-tracts.  Recur- 
rence is  rare.  According  to  the  region  affected  it  is  termed  zoster 
capitis,  zoster  frontalis,  zoster  faciei,  zoster  ophthalmicus,  zoster  auri- 
cularis,  zoster  nuchce,  zoster  hrachialis,  zoster  pectoralis,  zoster  ahdomin- 
alis,  zoster  femoralis. 

Diagnosis. — The  characteristics  of  herpes  zoster  are  the  pains  pre- 
ceding and  accompanying  the  eruption,  the  unilateral  distribution, 
and  the  grouped,  tense  vesicles  showing  no  tendency  to  rupture, 
situated  over  the  course  of  a  cutaneous"  nerve. 

Prognosis. — 'Most  cases  terminate  in  recovery  within  ten  days  or 
two  weeks.  Neuralgia  may  follow  the  disappearance  of  the  erup- 
tion. Herpes  zoster  ophthalmicus  may  give  rise  to  destructive  ocular 
lesions. 

Treatment. — The  pain  will  require  the  administration  of  antipyrin, 
gr.  XV  (i  gm.),  every  three  or  four  hours;  phenacetin,  gr.  v  (0.3  gm.), 
every  three  hours;  sodium  salicylate,  gr.  x  to  xv  (0.6  to  i  gm.),  every 


6o6  NEURALGIA 

three  hours;  or  if  very  severe,  morphine,  gr.  }4  (0.008  gm.),  and  atro- 
pine, gr.  3^00  (0.00065  gm.),  hypodermically,  near  the  lesion.  The 
following  combination  is  sometimes  of  value. 

I^,     Zinci  phosphidi. 

Ext.  nucis  vomicae aa  gr,  x  aa  0.6  gm. 

M.     Ft.  pil  No.  XXX. 

S. — One  every  two  to  four  hours  (Bulkley). 

Locally,  aristol,  boric  acid,  zinc  oxide,  and  similar  powders  dusted 
over  the  lesions  are  of  value.  Flexible  collodion,  containing  mor- 
phine, painted  over  the  vesicles  serves  to  protect  them  and  lessen 
the  pain. 

NEURALGIA 

Definition. — A  disease  of  the  nervous  system,  manifesting  itself 
by  sudden  pain  of  a  sharp  and  darting  character,  mostly  unilateral, 
following  the  course  of  the  sensory  nerves. 

Varieties. — The  most  important  are:  I.  Neuralgia  of  the  fifth 
nerve.  II.  Cervicooccipital  neuralgia.  III.  Cervicobrachial  neuralgia. 
IV.  D or sointer costal  neuralgia.  V.  Lumhoahdominal  neuralgia.  VI. 
Sciatica.     VII.  Erythromelalgia  (Mitchell). 

Causes. — The  most  important  etiological  factors  are  adult  life, 
female  sex,  heredity,  anemia,  malaria,  syphilis,  rheumatism,  metallic 
poisons,  gout,  anxiety,  mental  exertion,  exposure  to  cold  and  damp, 
injuries  to  the  nerve-trunks,  and  reflex  disturbances,  such  as  accom- 
pany eye-strain  and  dental  affections. 

Pathology.- — The  changes  in  the  nerves  are  very  vague.  Neuritis 
is  frequently  present.  The  true  nature  of  neuralgia  is  obscure.  An 
impoverished  condition  of  the  blood,  perhaps,  underlies  the  affection. 

NEURALGIA  OF  THE  FIFTH  NERVE 

Synonyms. — Tic-douloureux;  trifacial  neuralgia;  prosopalgia. 

Symptoms. — Paroxysmal  pain,  of  a  sharp,  darting,  stabbing 
character,  most  common  at  points  along  the  course  of  the  supra- 
and  infraorbital  branches  of  the  fifth  nerve,  attended  with  increased 
lacrimation,  is  characteristic  of  this  affection.  When  of  any  dura- 
tion, changes  are  observed  in  the  nervous  distribution,  such  as 
edema  along  the  course  of  the  nerve,  gray  eyebrows,  and  convulsive 
twitches  of  the  muscles,  termed  ^'tic-douloureux,'^  with  tenderness 


SCIATICA  607 

at  the  infra-  and  supraorbital  foramina,  as  well  as  along  the  course 
of  the  nerve  distribution. 

CERVICO -OCCIPITAL  NEURALGIA 

Paroxysmal  pain,  of  a  sharp  and  lancinating,  or  deep,  heavy, 
tensive  character,  along  the  course  of  the  occipital  nerve  upon  one 
or  both  sides,  extending  from  the  vertex,  and  on  the  neck  as  far 
down  as  the  clavicle,  and  upward  and  forward  to  the  cheek.  It 
may  be  associated  with  hyperesthesia  of  the  skin,  and  with  cramps 
in  the  cervical  muscles,  and  with  attacks  of  herpes.  A  sensation  of 
cracking  at  the  nape  of  the  neck  is  an  annoying  symptom  in  many 
cases. 

CERVICOBRACHIAL  NEURALGIA 

Paroxysmal  pain  of  a  severe,  boring,  burning,  or  tensive  character, 
with  sensations  of  numbness  and  weakness  of  the  arm,  hand,  shoulder, 
scapula,  and  mamma,  with  tenderness  along  the  cervical  plexus. 
Edema  of  the  arm  and  other  parts  along  the  distribution  of  the 
cervical  plexus  occurs  if  the  neuralgia  be  of  long  duration;  as  the 
result  of  nutritive  changes,  the  limb  at  times  becoming  pale,  the 
skin  glossy,  dry,  and  harsh. 

DORSOINTERCOSTAL  NEURALGLA. 

Paroxysmal  pain,  of  a  sharp,  and  lancinating  character,  along  the 
fifth  and  sixth  intercostal  spaces,  often  associated  with  the  develop- 
ment of  herpes  zoster,  or  "shingles.''  Tenderness  is  present  at  the 
points  where  the  nerves  emerge  from  the  intervertebral  foramina 
at  the  sides  of  the  chest  and  at  points  in  front. 

LUMBOABDOMINAL  NEURALGLA. 

Paroxysmal  pain,  of  a  sharp,  and  lancinating,  at  times  heavy  and 
dull,  character,  following  the  course  of  the  iliohypogastric  nerve, 
ilioinguinal  and  external  spermatic  nerve,  supplying  the  integument 
of  the  hip,  the  inner  side  of  the  thigh,  the  scrotum  and  labia. 

SCIATICA 

Paroxysmal  pain  following  the  course  of  the  sciatic  nerve  usually 
as  the  result  of  a  neuritis. 


6o8  ERYTHROMELALGIA 

S3miptoms. — Sciatica  usually  follows  an  attack  of  lumbago,  the 
pain  becoming  fixed  in  the  sciatic  nerve;  at  times  it  is  a  true  neuritis. 

The  pain  is  sharp,  tearing,  shooting,  or  lancinating  in  character, 
increased  upon  motion,  shooting  along  the  course  of  the  nerve  into 
the  hip,  inner  side  of  the  thigh,  calf  of  the  leg,  ankle,  and  heel,  at 
one  or  all  of  these  points,  in  paroxysms  lasting  from  a  few  hours 
to  twenty-four  hours  or  longer.  Tactile  sensation  in  the  foot  and 
mobility  in  the  limbs  are  impaired,  and  if  of  long  duration,  wasting 
of  the  limb  occurs. 

ERYTHROMELALGIA 

Synonym. — "Red  neuralgia." 

Symptoms. — In  this  form  of  neuralgia,  the  feet  principally  are 
affected  by  intense  redness  and  burning  pain.  For  a  considerable 
period  before  the  condition  is  typically  developed  there  are  aching 
pains  in  the  feet,  particularly  when  used.  The  feet,  in  Dr.  Mitchell's 
words,  ''get  redder  and  redder,  the  veins  stand  out  in  a  few  minutes 
as  if  a  ligature  had  been  tied  about  the  limb,  and  the  arteries  throb 
violently  for  a  time,  until  at  length  the  extremities  become  of  a 
dark  purplish  tint."  As  a  rule,  the  redness  only  occurs  when  the 
feet  hang  down,  and  when  at  rest  they  may  be  pale  and  perspire 
freely.     Blisters  and  ulcers  follow  slight  contusions  of  the  feet. 

Diagnosis. — Erythromelalgia  has  been  confounded  with  Ray- 
naud's disease.  The  presence  of  pain,  bright  redness,  throbbing  and 
increased  temperature  of  the  part  are  all  the  opposite  of  Raynaud's 
disease. 

Prognosis  of  All  Forms  of  Neuralgia. — The  attack  can  usually  be 
relieved,  and  in  those  cases  in  which  the  underlying  cause  can  be 
ascertained  and  removed,  the  outlook  is  favorable  for  permanent 
cure.  If  the  neuralgia  is  the  result  of  the  pressure  of  an  exostosis, 
aneurysm,  or  other  tumor,  the  prognosis  is  unfavorable.  The 
variety  known  as  erythromelalgia  is  very  persistent.  Fifth  nerve 
neuralgia  is  likewise  very  obstinate  to  treatment. 

Treatment  of  Neuralgia  in  General. — During  the  intervals  between 
the  attacks,  the  general  health  should  be  improved  and  all  possible 
sources  of  reflex  disturbance  should  be  carefully  removed.  The 
diet  should  be  highly  nutritious  and  medication  suitable  for  the 
individual  case  should  be  employed.  In  anemic  patients  iron  and 
arsenic  should  be  used;  in  rheumatic  persons,  the  alkalies  and  sali- 
cylates should  be  given;  in  syphilitic  cases  or  those  due  to  mineral 


ERYTHROMELALGIA  609 

poisons,  potassium  iodide  should  be  administered;  and  in  the  presence 
of  malaria,  quinine  sulphate  or  hydrochloride  should  be  employed. 
Undue  physical  or  mental  excitement,  exposure  to  cold  and  wet,  and 
excesses  of  various  kinds  should  be  avoided.  The  following  pill  is 
of  great  value  in  all  cases: 

I^.     Quininae    sulphat gr-  ij  0.13    gm. 

Morphinae  sulphat gr.  3^o  0.003  gm- 

Strychninae  sulphat gr.  ^-^o  0.002  gm. 

Acidi  arsenosi gr.  }4o  0.003  grn* 

Extracti  aconiti gr.  M  0.032  gm. 

M.    Ft.  pil.  No.  j. 

S. — One  every  one,  two,  or  three  hours  (S.  D.  Gross). 

All  forms  of  neuralgia  are  more  or  less  benefited  by: 

I^.     Quininae  sulph gr.  iij  0.2  gm. 

Ferri   reduct gr.  j  o .  065  gm. 

Acid,  arsenosi gr.  Mo  0.003  gni* 

Aconitinae gr.  H20  0.00054  gi^« 

M.  S. — In  pill,  every  four  or  five  hours. 

The  condition  of  the  eyes,  ears,  nose,  throat,  and  teeth  should 
always  receive  careful  attention.  The  presence  of  eye-strain, 
cerumen,  adenoids,  dental  caries,  etc.,  may  be  the  origin  of  reflex 
disturbances  that  ultimately  become  neuralgias.  The  relation 
between  them  is  not  always  apparent  so  that  in  all  cases  these  struc- 
tures should  be  examined  as  a  matter  of  routine. 

During  an  attack,  the  hypodermic  injection  of  morphine  sulphate 
and  atropine  sulphate  affords  the  most  prompt  and  ready  relief. 
Acetanilid,  phenacetin,  bromides,  caffeine,  salicylic  acid  prepara- 
tions, and  cannabis  indica  may  also  be  used  but  are  less  efficacious. 
Moist  or  dry  heat,  chloroform  liniment,  menthol  and  chloral-cam- 
phor applications,  acupuncture,  and  counter-irritation  may  be 
employed  locally. 

In  trigeminal  neuralgia,  the  following  combination  is  productive 
of  great  benefit: 

I^.     Aconitinae  (Duquesnel) ...  .   gr.  Ho  0.006  gm. 

Glycerini, 

Alcoholis aa  f  5  j  S3,       4.0     c.c. 

Aquae  menth.  pip.,  .q.  s.  ad  f  5ij  ad     60.0     c.c. 

M.  S. — Teaspoonful,  repeated  from  four  to  eight  times  daily, 
carefully  watched. 
39 


6lO  FACIAL  PARALYSIS 

In  intercostal  neuralgia,  the  following  is  recommended: 

I^.     Chloral 3]  4  gm. 

Piilv.  camphoras 5j  4  gm. 

Menthol 3j  4  gm. 

M.     Mix  and  rub  together. 

S. — Paint   over   painful   parts    with  brush,    as   the   occasion 
requires. 

Facial  neuralgia  is  often  wonderfully  benefited  by  the  administra- 
tion of  fluidextract  of  gelsemium,  TTliij  to  v  (0.2  to  0.3  c.c.),  every 
three  or  four  hours  until  its  physiologic  effects  are  produced.  It 
may  be  combined  with  cannabis  indica  or  belladonna.  Excellent 
results  often  follow  the  use  of  aconite  and  quinine,  in  pill  form. 

In  sciatica,  antipyrine,  antifebrin,  or  phenacetin,  gr.  xx  (1.3  gm.), 
repeated  two  or  three  times  daily  may  afford  relief.  Bartholow 
recommends  deep  injections  of  chloroform.  Nitroglycerin  may  be 
of  benefit,  beginning  with  i  drop  of  a  i  per  cent,  solution,  three 
or  four  times  daily,  and  gradually  increasing  the  dose  until  4  or  5 
drops  are  taken  several  times  daily.  Mitchell  advocates  the  applica- 
tion of  a  flannel  bandage  to  the  entire  leg,  changed  daily,  and  a 
splint  reaching  from  the  axilla  to  the  heel,  held  closely  to  the  limb. 
This  procedure  insures  absolute  rest  for  the  part.  Tonics  should 
also  be  employed.  A  spray  of  chloride  of  ethyl  along  the  course  of 
the  nerve  for  a  few  moments  often  serves  to  relieve  the  distressing 
pain.  Occasionally,  the  administration  of  full  doses  of  potassium 
iodide  and  the  application  of  a  blister  along  the  course  of  the  nerve 
will  be  of  benefit.  Massage,  acupuncture,  nerve-stretching  and 
electricity,  and  similar  procedures  may  be  tried  in  obstinate  cases. 

In  erythromelalgia,  medication  has  been  of  no  avail.  Rest  and 
elevation  of  the  limb  afford  relief  in  many  cases.  Mitchell  recom- 
mends either  nerve-stretching,  or  in  aggravated  cases  nerve-excision. 

FACIAL  PARALYSIS 

S3nionyin. — Bell's  palsy. 

Definition. — An  acute  paralysis  of  the  seventh  cranial — the  facial 
nerve,  the  great  motor  nerve  of  the  muscles  of  the  face — the  nerve  of 
expression. 

Causes. — Exposure  to  a  current  of  cold  air  against  the  side  of  the 
face — over  the  pes  anserinus — is  the  most  frequent  cause.  It  may 
also  be  due  to  injury  or  disease  of  the  middle  ear  involving  the 


FACIAL   PARALYSIS  6ll 

nerve,  tumor,  blood-clot,  or  abscess  in  the  cortical  area  or  nucleus 
of  the  seventh  nerve,  or  at  the  base  of  the  brain,  syphilis,  rheumatism, 
or  the  infectious  fevers. 

Symptoms. — The  facial  nerve  supplies  the  muscles  of  the  face, 
the  muscles  of  the  external  ear,  also  the  stylohyoid,  posterior  belly 
of  the  digastric,  the  platysma,  one  muscle  of  the  middle  ear  (the 
stapedius)  and  one  palate  muscle  (the  levator  palati);  by  means  of 
the  chorda  tympani  branch  it  controls  the  secretion  of  the  parotid 
and  submaxillary  glands,  and,  possibly,  the  sense  of  taste.  It  also 
furnishes  motor  power  to  the  azygos  uvulae,  the  tensor  tympani, 
and  the  tensor  palati  muscles. 

The  onset  is  usually  sudden,  with  tingling  of  the  lips  and  tongue 
and  upon  looking  into  the  mirror  the  patient  is  surprised  by  the  per- 
fectly blank,  motionless  side  of  his  face;  the  corner  of  the  mouth 
is  depressed,  the  eyelids  open,  the  face  drawn  toward  the  well 
side,  and  the  patient  is  unable  to  expectorate,  whistle,  or  swallow. 

Any  of  the  muscles  innervated  by  the  nerve  may  participate  in 
the  paresis. 

The  electro-contractility  is  feeble  or  lost.  The  reflexes  are 
abolished.  If  there  is  loss  of  taste  in  the  anterior  portion  of  the 
tongue,  it  indicates  involvement  of  the  nerve  in  its  passage 
through  the  temporal  bone. 

Diagnosis. — Facial  paralysis,  such  as  accompanies  hemiplegia,  and 
similar  affections  is  attended  by  normal  reflex  excitability  and 
cerebral  symptoms  due  to  involvement  of  other  nerves.  Facial 
palsy,  in  the  presence  of  otorrhea,  imperfect  hearing,  obliquity  of 
the  uvula,  and  loss  of  taste,  is  due  to  a  lesion  of  the  nerve  in  the 
aqueductus  Fallopii.  The  peripheral  form  of  Bell's  palsy  is  com- 
plete and  the  taste  is  normal  and  the  uvula  straight. 

Prognosis. — In  cases  of  peripheral  origin  the  outlook  is  favor- 
able. In  others,  it  depends  entirely  upon  the  character  of  the 
underlying  cause  and  the  ease  with  which  it  may  be  removed. 

Treatment.— In  peripheral  facial  neuritis,  the  bowels  should  be 
opened  thoroughly  and  the  salicylates  administered.  Diaphoresis 
should  be  obtained  by  the  hot  bath  and  pilocarpine  or  diuresis  by 
means  of  potassium  acetate  and  diluents.  Blisters  should  be  applied 
in  front  of  the  ear.  As  the  acute  symptoms  subside,  potassium 
iodide  and  strychnine  should  be  given  and  galvanism  and  massage 
should  be  applied  to  the  affected  muscles.  In  cases  due  to  middle- 
ear  disease  special  treatment  is  necessary.     In  paralysis  of  central 


6l2 


PARALYSIS  OF  THE  LARYNGEAL  MUSCLES 


origin,  the  iodides  may  be  employed,  but  apart  from  this  medica- 
tion is  of  little  avail. 

PARALYSIS  OF  THE  LARYNGEAL  MUSCLES 

Etiology. — Central  nervous  lesions,  as  bulbar  paralysis;  per- 
ipheral nervous  lesions,  affecting  the  recurrent  laryngeal  nerve 
(such  as  aortic  aneurysm,  tumor  of  mediastinum,  diphtheritic  par- 
alysis); local  lesions  of  the  vocal  cords  (such  as  ulceration  due  to 
syphilis,  or  tuberculosis);   and  hysteria. 

Fig.  59. — Vocal  cords 
(Diagrammatic  mirror  pic- 
ture). I,  Normal  position 
in  breathing  and  phonation 
respectively;  2,  adductor 
paralysis  (left)  2',  bilateral 
adductor  paralysis,  _  Both 
in  phonation;  3,  unilateral 
abductor  (left)  and  3',  bilat- 
eral abductor  paralysis 
both  during  breathing;  4, 
left  recurrent  paralysis  pho- 
nation; 4',  same  in  respi- 
ration; 4",  recurrent  bilat- 
eral in  both  respiration  and 
phonation;  5,  arytenoid  par- 
alysis phonation,  5',_  Thy- 
ro-arytenoid  paralysis, pho- 
nation; 5",  arytenoid  and 
thyro-arytenoid  paralysis. 
{Greene's  Medical  Diagno- 
sis.) 

The  nerves  involved  are  the  superior  laryngeal  and  the  recurrent 
laryngeal  (both  branches  of  the  pneumogastric  nerve). 

The  following  oft-quoted  table  from  Gowers  shows  the  symptoms, 
laryngoscopic  picture,  and  lesions: 


Symptoms 


Signs 


Lesion 


(a)  No  voice;  no  cough;  stridor 
only  on  deep  inspiration. 

(&)  Voice  low-pitched  and 
hoarse;  no  cough;  stridor 
absent^  or  slight  on 
breathing. 

(c)  Voice  httle  changed;  cough 
normal;  inspiration  diffi- 
cult and  long,  with  loud 
stridor. 

(d)  Symptoms  ^  inconclusive; 
little  affection  of  the  voice 
or  cough. 

(e)  No_  voice;  perfect  cough;  no 
stridor  or  dyspnea. 


Both  cords  moderately  abducted 
and  motionless. 

One  cord_  moderately  abducted 
and  motionless,  the  other  mov- 
ing freely  and  even  beyond  the 
middle  Hne  in  phonation. 

Both  cords  near  together,  and 
during  inspiration  not  separated, 
but  even  drawn  nearer  together. 

One  cord  near  the  middle  line,  not 
moving  during  inspiration;  the 
other  normal. 

Cords  normal  in'position  and  mov- 
ing normally  in  respiration,  but 
not  brought  together  on  an 
attempt  at  phonation. 


Total    bilateral 

palsy. 
Total  unilateral 
palsy. 


Total    abductor 
palsy. 


Unilateral  abductor 
palsy. 

Adductor  palsy. 


Treatment  is  that  of  the  cause;  electricity  and  strychnine  have 
also  been  employed. 


CHOREA  613 

GENERAL  NERVOUS  DISEASES 

CHOREA 

Synonyms. — St.  Vitus'  dance;  Sydenham's  chorea. 

Definition. — A  functional  disorder  of  the  nervous  system;  charac- 
terized by  irregular  spasmodic  fibrillary  movements  of  groups  of 
muscles,  with  weakness,  more  or  less  approaching  paralysis  of  the 
affected  parts.  Excitement  increases  these  movements,  while  sleep 
causes  their  cessation. 

Causes. — It  is  essentially  a  disease  of  childhood,  and  its  production 
may  be  greatly  influenced  by  female  sex,  rheumatic  diathesis,  habit, 
neurotic  temperament,  heredity,  mental  excitement,  spring  season, 
and  reflex  disturbances  such  as  produced  by  adherent  prepuce, 
masturbation,  worms,  dentition,  eye-strain,  etc.  The  affection 
may  be  observed  at  times  during  pregnancy  and  after  hemiplegia. 

Pathology. — There  are  no  constant  lesions.  Emboli  are  believed 
to  be  the  cause  in  some  cases.  The  affection  is  believed  by  many 
observers  to  be  a  neurosis  and  by  others  an  infection. 

Symptoms. — The  onset  is  usually  gradual,  the  child  seemingly 
grimacing  or  jerking  the  arm  or  hand,  as  if  in  imitation,  followed  soon 
by  decided  irregular  jactitations  of  the  muscles  of  the  face  (histrionic 
spasm),  of  the  eyelids  (blepharospasm),  eyeballs  (nystagmus),  and 
the  shoulder,  arm,  and  hand,  finally  extending  to  the  lower  extremi- 
ties, interfering  greatly  with  motility;  in  severe  cases  there  is  inability 
on  the  part  of  the  patient  to  feed  himself  or  to  hold  anything  in  the 
hands.  The  speech  is  often  unintelligible,  the  tongue  constantly 
moving  in  an  irregular  manner. 

The  heart's  action  is  tumultuous  and  irregular,  associated  often- 
with  a  soft,  blowing,  systolic  murmur,  most  distinct  at  the  base. 
The  muscles  are  usually  quiet  during  sleep,  although  this  is  not 
always  the  case.  The  mind  is  somewhat  blunted,  the  temper  irri- 
table, and  the  memory  impaired.  If  the  irregular  muscular  move- 
ments are  confined  to  one  side  of  the  body,  it  is  termed  hemichorea. 

Rheumatism  and  endocarditis  may  occur  as  complications  or  as 
sequels. 

Diagnosis. — Chorea  was  confounded  with  epilepsy  until  the  points 
of  distinction  were  pointed  out  by  Sydenham. 

Huntington's  chorea  or  chronic  chorea  is  distinctly  hereditary,  and, 
instead  of  being  fibrillary  contraction  of  muscles,  involves  whole 


6 14  CHOREA 

groups  of  muscles,  so  that  the  patient  seems  to  be  posturing  and 
grimacing,  with  a  dancing  movement,  with  many  queer  contortions 
of  the  face  and  head.  Generally,  all  the  muscles  of  the  body  are 
involved.  It  may  have  associated  the  fibrillary  muscular  contrac- 
tions of  St.  Vitus'  dance. 

Paralysis  agitans  has  general  muscular  tremor,  beginning  in  one 
limb,  gradually  progressing,  uninfluenced  by  treatment;  it  is  a  disease 
of  the  elderly. 

Post-hemiplegic  chorea  is  the  choreic  movement  of  a  paralyzed 
limb. 

Chorea  insaniens  is  characterized  by  violent  movements  prevent- 
ing ordinary  voluntary  movement  and  attended  by  fever,  delirium, 
and  exhaustion,  sometimes  ending  in  death.  It  occurs  most  often 
in  adults. 

Prognosis. — The  vast  majority  of  cases  recover,  but  relapses  are 
very  frequent. 

Treatment. — The  child  should  be  removed  from  all  excitemxcnt, 
mental  and  physical,  and  placed  at  comparative  rest  among  the  best 
hygienic  surroundings.  Many  cases  improve  rapidly  when  confined 
to  bed  in  a  darkened  room.  The  diet  should  be  light  and  the  secre- 
tions should  be  rendered  free.  The  cause  should  be  removed  if 
possible.  All  reflex  irritation  such  as  accompanies  eye-strain, 
intestinal  parasites,  dental  disorders,  adherent  prepuce,  etc.,  should 
receive  appropriate  attention. 

Arsenic  is  the  most  reliable  remedy  yet  introduced  for  the  treat- 
ment of  this  affection.  It  should  be  pushed  until  its  first  physio- 
logical effects  present  themselves,  after  which  the  dose  should  be 
gradually  reduced  until  all  the  symptoms  disappear.  The  best 
preparation  for  use  in  this  connection  is  the  solution  of  the  arsenite 
of  potassium  (Fowler's  solution),  TTlv  (0.3  c.c),  increased  to  TTlx 
(0.6  c.c),  or  even  TUxv  (i  c.c),  three  times  daily.  Fluidextract  of 
cimicifuga,  TTlxx  to  f 5j  (1.3  to  4  c.c),  three  times  daily  is  of  value, 
especially  in  cases  following  rheumatism.  Those  cases  resisting 
arsenical  medication  may  rapidly  improve  under  hyoscyamine 
hydrobromide,  gr.  l^ioo  to  3^oo  (0.00032  to  0.00065  g^-)j  three 
times  daily.  Obstinate  cases  occasionally  respond  to  antipyrine, 
gr.  x  (0.6  gm.),  four  times  daily.  Quinine  is  also  of  benefit  at  times. 
In  anemic  individuals  iron  should  be  administered.  If  the  muscular 
movements  interfere  with  sleep,  recourse  should  be  had  to  hyoscine, 
bromides,  chloral,  or  morphine  sulphate. 


EPILEPSY  615 

EPILEPSY 

Definition. — A  chronic  disease,  of  which  the  characteristic  symp- 
tom is  a  sudden  loss  of  consciousness,  attended  with  more  or  less 
general  convulsions. 

Causes. — True  epilepsy  almost  always  arises  first  during  the 
growth  and  development  of  the  brain.  Heredity  exercises  a  very 
strong  predisposing  influence.  The  family  history  in  many  cases 
contains  records  of  insanity,  epilepsy,  hysteria,  and  similar  conditions 
in  the  relatives  of  the  patient.  Worry,  anxiety,  depression,  fright, 
syphilis,  uterine  disease,  brain  tumor,  and  meningeal  thickening 
may  at  times  be  etiological  factors.  Reflex  irritation  from  intestinal 
parasites,  eye-strain,  etc.,  may  induce  epileptoid  convulsions  which 
if  long-continued  may  bring  about  true  chronic  epilepsy.  The 
affection  usually  manifests  itself  before  puberty  and  seldom  begins 
after  twenty-five  years  of  age.  Reed  believes  that  the  disease  is  of 
bacterial  origin,  and  calls  the  organism  the  Bacillus  epilepticus. 

Pathological  Anatomy. — There  are  no  constant  anatomical  lesions, 
as  yet,  associated  with  essential  epilepsy. 

In  "Jacksonian,"  "cortical,"  or  ''partial  epilepsy,"  however,  the 
"motor  cortex"  is  irritated  by  disease  and  there  occur  tonic  and 
clonic  spasms  of  the  same  character  as  in  general  epilepsy,  confined 
to  a  single  arm,  or  an  arm  and  half  the  face  together,  or  maybe  the 
entire  half  of  the  body.  These  epileptiform  attacks  furnish  precise 
data  as  to  the  locality  of  the  lesion;  spasms  affecting  the  distribu- 
tion of  the  facial  nerve  point  to  the  lower  third  of  the  central  convolu- 
tion; of  the  arm,  the  middle  third  of  the  central  convolution;  of  the 
lower  extremity,  the  upper  third  of  the  central  convolution. 

Varieties. — I.  Epilepsia  gravior,  le  grand  mal.  II.  Epilepsia 
mitior,  le  petit  mal. 

Symptoms. — Le  grand  mal  is  preceded  by  a  more  or  less  pronounced 
and  curious  sensation,  the  so-called  aura  epileptica. 

The  attack  proper  is  sudden,  the  subject  suddenly  falling,  with  a 
peculiar  cry,  loss  of  consciousness,  and  pallor  of  the  face,  the  body 
assuming  a  position  of  tetanic  rigidity,  succeeded  after  a  few  mo- 
ments by  more  or  less  pronounced  clonic  convulsions,  followed  by 
coma,  of  several  hours'  duration.  The  subject  awakens  with  a 
confused  or  sheepish  expression,  with  no  knowledge  of  what  has 
occurred,  unless  he  has  injured  himself  during  the  attack,  either  by 
the  fall,  or,  what  is  very  common,  has  bitten  his  tongue  during  the 


6l6  EPILEPSY 

convulsions.  The  pupils  are  dilated  and  do  not  react  to  light. 
Immediately  after  the  attack  the  knee-jerks  may  be  abolished  but 
soon  return,  exaggerated.  When  the  convulsions  follow  each  other 
in  rapid  succession  without  any  intervening  periods  of  consciousness, 
the  condition  is  termed  status  epilepticus.  The  convulsive  out- 
breaks may  be  followed  by  maniacal  attacks  or  the  condition  known 
as  post-epileptic  automatism,  during  which  various  acts  are  performed 
unconsciously  by  the  patient. 

Le  petit  mat  is  manifested  either  by  attacks  of  vertigo,  the  con- 
sciousness being  preserved,  or  by  a  passing  absent-mindedness, 
either  form  being  associated  with  slight  convulsive  phenomena 
followed  by  slight  coma,  or  mental  confusion  of  short  duration. 

The  mental  functions  are  not,  as  a  rule,  injured  by  attacks  of 
epilepsy,  unless  they  recur  very  frequently.  Indeed,  when  at  wide 
intervals,  the  "subject  seems  relieved  by  them,  "the  sudden,  excessive, 
and  rapid  discharge  of  gray  matter  of  some  part  of  the  brain  on  the 
muscles,"  the  so-called  "electric  storm,"  having  cleared  the  cerebral 
atmosphere. 

The  great  majority  of  epileptics  suffer  from  chronic  gastric  catarrh, 
and  have  at  the  same  time  an  inordinate  appetite  (bulimia) ;  indeed, 
an  attack  of  gluttony  may  immediately  precede  a  fit.  The  liability 
of  patients  suffering  from  epilepsy  to  develop  tuberculosis  and  neph- 
ritis is  very  great. 

Diagnosis. — Uremic  convulsions  closely  resemble  epileptic  attacks, 
but  the  dropsy  or  general  edema  and  albuminous  urine,  and  increased 
temperature  of  the  former  should  guard  against  error. 

Hysteria  or  feigned  convulsions  may  mislead  the  most  practised 
expert.  In  convulsions  of  this  character,  however,  consciousness 
is  seldom  completely  lost;  the  patient  is  never  injured  in  any  way; 
the  temperature,  pulse,  and  respiration  remain  normal;  arching  of 
the  back  occurs  (opisthotonos  is  absent  in  epilepsy) ;  and  the  duration 
is  longer.  In  epilepsy,  there  is  primary  pallor  of  the  face  which  is 
followed  by  a  dusky,  livid,  and  swollen  appearance  during  the  con- 
vulsion, this  being  replaced  by  ordinary  congestion  during  the  period 
of  coma.  Relaxation  of  the  sphincters  is  common  in  attacks  of 
grand  mat. 

Strychnine- poisoning. — The  convulsions  begin  with  clonic  spasms, 
which  later  become  tonic,  and  are  accompanied  by  opisthotonos. 
The  patient  does  not  lose  consciousness.  There  are  periods  of  inter- 
mission when  the  muscles  are  relaxed. 


EPILEPSY  617 

In  tetanus,  the  convulsions  are  tonic  from  the  beginning,  with 
spasm  of  the  muscles  of  the  jaw,  and  opisthotonos.  There  is  no 
complete  muscular  relaxation. 

In  rabies  there  is  tonic  spasm  of  the  muscles  of  deglutition,  spread- 
ing to  other  muscles  especially  those  of  respiration;  there  may  be 
severe  opisthotonos  at  the  end. 

Organic  brain  disease  may  be  distinguished  from  epilepsy  by  the 
occurrence  of  its  convulsions  at  a  much  later  period  in  life,  the 
character  of  the  convulsions,  and  the  history  of  injury,  syphilis,  etc. 
Jacksonian  epilepsy  begins  as  a  spasm  of  a  limb  or  some  portion  of  a 
limb,  and  is  confined  there,  or  may  gradually  extend  from  one  cortical 
center  to  another  until  even  a  general  convulsion  occurs. 

Prognosis. — In  idiopathic  epilepsy  the  prognosis  is  unfavorable; 
the  vast  majority  of  cases  will  not  be  arrested  by  treatment,  but  the 
frequency  and  severity  of  the  attacks  will  be  greatly  diminished. 
Epileptoid  convulsions  of  reflex  origin  such  as  sometimes  accompany 
intestinal  parasites,  eye-strain,  etc.,  usually  recover  promptly  when 
the  cause  is  removed. 

Treatment. — The  attack:  To  avert  an  impending  attack  inhala- 
tions of  amyl  nitrite,  Tfliij  to  v  (0.2  to  0.3  c.c),  or  a  few  whiffs  of 
chloroform,  or  the  hypodermic  injection  of  morphine  sulphate  may 
be  employed.  Hyoscine  and  chloral  may  also  be  used.  These 
remedies  are  also  indicated  after  the  onset  of  the  convulsion.  Means 
should  be  taken  to  prevent  the  patient  seriously  injuring  the  tongue; 
to  this  end  a  portion  of  a  towel,  or  a  long  piece  of  wood  such  as  a 
clothes  pin,  or  the  handle  of  a  tooth  brush  should  be  inserted  between 
the  teeth.  Small  objects  so  used  are  dangerous.  The  patient  should 
also  be  prevented  from  otherwise  injuring  himself  and  on  the  sub- 
sidence of  the  convulsion  should  be  placed  comfortably  at  rest  in  a 
quiet  room. 

Status  epilepticus  is  always  a  dangerous  condition,  and  efforts 
to  prevent  it  should  be  made  by  active  medication  the  moment  a 
series  or  group  of  fits  occurs.  The  following  combinations  sometimes 
are  wonderfully  successful  in  aborting  the  status: 

I^.     Chloral gr.  xxx  2  gm. 

Tinct.  cannab.  indicse ITlxv  i  c.c. 

Infus.  digitalis f  5  J  30  c.c. 

M.  S. — By  high  enema,  repeated  if  indicated  in  two  or  three 
hours. 


6l8  •  EPILEPSY 

o 

Dr.  Spratling  (Craig  Epileptic  Colony)  recommends: 

I^.     Tinct.  opii  deodorat lUv  0.3    c.c. 

Potassii  bromidi gr.  xxx  2  .0    gm. 

Chloral gr.  xx  1.3    gm. 

Liq.  morph.  (U.  S.) TTljss  0.09  c.c. 

Aquae fBss  15.0    c.c. 

M.  S. — By  mouth,  or,  if  unable  to  swallow,  by  enema. 

A  hypodermic  injection  of  morphine  sulphate,  gr.  ^  (0.02  gm.), 
and  atropine  sulphate,  gr.  }4o  (o.ooi  gm.),  has  sometimes  broken  up 
a  series  of  epileptic  spasms. 

The  interval:  During  the  interval,  the  patient  should  be  carefully 
examined  to  determine  the  character  of  any  exciting  causes.  Reflex 
disturbances  of  all  kinds  should  be  promptly  removed  by  treatment. 
The  diet  must  be  carefully  regulated,  excluding  or  allowing  to  be 
used  very  moderately,  meats,  tea,  and  coffee.  Alcohol  and  tobacco 
should  be  interdicted.  The  skin,  kidneys,  and  bowels  should  be 
kept  in  normal  condition  by  appropriate  measures.  Moderate 
exercise  is  of  great  value.  When  the  patient's  ■  general  condition 
is  below  normal,  iron,  arsenic,  quinine,  and  cod-liver  oil  are 
indicated.  Strychnine  is  contraindicated  as  it  increases  the  tendency 
to  convulsive  attacks. 

In  addition  to  the  measures  already  mentioned,  the  frequency 
and  severity  of  the  attacks  may  be  greatly  lessened  by  the  internal 
administration  of  potassium  bromide  in  doses  sufficient  to  abolish  the 
faucial  reflex  and  to  produce  symptoms  of  bromism.  Combinations 
of  the  several  bromides  are  equally  efficacious  and  less  irritating 
than  the  potassium  salt.  Any  tendency  toward  the  formation  of 
acne  pustules  during  the  administration  of  the  bromides  may  be 
combated  by  the  addition  of  i  drop  of  Fowler's  solution  to  each  dose. 
When  for  any  reason  the  bromides  are  inapplicable,  silver  nitrate, 
belladonna,  or  cannabis  indica  may  be  used.  In  syphilitic  cases, 
potassium  iodide  should  be  given  in  addition.  In  all  cases  the 
treatment  must  be  continued  for  at  least  two  years  after  the  last 
attack. 

Gowers  highly  recommends  the  following  in  cases  complicated 
with  cardiac  dilatation: 

I^.     Potassii  bromidi gr.  xx  1.3  gm. 

Tinct."  digitalis. T([x  0.6  c.c. 

M.  S. — Three  times  a  day,  well  diluted. 


HYSTERIA  619 

The  following  is  the  combination  used  in  the  insane  wards  of  the 
Philadelphia  Hospital: 

I. 
I^.     Sodii  bromidi, 

Potassii  bromidi aa    5iv  aa  16  gm. 

Liq.  potassii  arsenitis f  5jss  6  c.c. 

Aquae  menthae  pip f^iij  90  c.c. 

Inf.  gentian,  comp.q.  s.  ad  fSviij  ad    240  c.c. 

M.  S. — Tablespoonful,  diluted,  three  times  daily. 

Brown-Sequard's  mixture  for  epilepsy  is  as  follows: 

I^.     Potassii  iodidi 8  parts. 

Potassii  bromidi 8  parts. 

Ammonii  bromidi 4  parts. 

Potassii  bicarb 5  parts. 

Inf.   calumbae 360  parts. 

M.    S. — One    teaspoonful    before    meals,    and    three    dessert- 
spoonfuls on  going  to  bed. 

The  following  is  an  effective  combination  of  the  "mixed  bromides : " 

I^.     Sodii  bromidi Bj  30  gm. 

Potassii  bromidi 5  ^ss  22  gm. 

Ammonii  broniidi 5iij  12  gm. 

Potassii  bicarb 5  ij  8  gm. 

Inf.    calumbae fgx  300  c.c. 

Aq.  chloroformi. .  .  .q.  s.  ad  Oj  ad     480  c.c. 

M.  S. — Tablespoonful  equals  gr.  xxx  (2  gm.). 

Surgical  intervention  may  be  of  value  in  some  cases  of  Jacksonian 
epilepsy,  but  in  general  it  is  somewhat  disappointing  in  its  results. 

HYSTERIA 

Definition. — A  functional  disorder  of  the  nervous  system,  of  the 
nature  of  which  it  is  impossible  to  speak  definitely;  characterized  by 
disorders  of  the  will,  reason,  imagination,  and  the  emotions,  as  well 
as  motor  and  sensory  disturbances. 

Hypochondriasis,  a  peculiar  mental  condition,  characterized  by 
inordinate  attention  on  the  part  of  the  patient  to  some  real  or  sup- 
posed bodily  ailment  or  sensation.  A  continual  introspection,  as 
seen  in  males,  is  a  condition  much  like  the  hysteria  of  the  female. 

Causes. — A  morbid  condition  of  civilization,  confined  principally 


620  HYSTERIA 

to  women.  Young  girls,  elderly  single  women,  widows,  and  childless 
married  women  are  the  most  frequent  subjects  of  the  disorder. 
The  paroxysms  frequently  develop  during  the  menstrual  epoch. 
The  menopause  is  another  frequent  period  for  its  manifestations. 
A  peculiar  condition  of  the  nervous  system,  either  inherited  or 
acquired,  is  responsible  for  the  phenomena  of  hysteria,  the  peculiar 
manifestations  being  excited  by  disturbances  of  either  the  sexual, 
digestive,  circulatory,  or  nervous  systems. 

Pathology. — The  true  nature  of  the  affection  is  unknown.  Struc- 
tural changes  are  never  found  except  when  the  condition  complicates 
some  organic  disease. 

Symptoms. — These  will  be  considered  under  the  headings  of  the 
hysterical  paroxysm,  and  the  hysterical  state. 

The  hysterical  paroxysm  or  fit  occurs  nearly  always  in  the  presence 
of  other  individuals  and  develops  gradually  with  sighing,  meaningless 
laughter,  causeless  moaning,  nonsensical  talking,  and  gesticulations, 
or  a  condition  of  fidgets  followed  with  a  sensation  of  choking,  dyspnea, 
and  a  ball  in  the  throat — the  globus  hystericus.  These  and  similar 
symptoms  precede  the  fit,  during  which  the  unconsciousness  is 
only  apparent,  the  patient  being  aware  of  what  is  transpiring  about 
her.  During  the  paroxysm  the  patients  may  struggle  violently, 
throwing  themselves  about,  their  thumbs  turned  in  and  their  hands 
clenched.  Again,  spasmodic  movements  occur,  varying  from  slight 
twitching  in  the  limbs  to  powerful  general  convulsive  movements, 
and  to  almost  tetanic  spasms. 

The  paroxysm  ends  by  sighing,  laughing,  crying,  and  yawning, 
and  a  sensation  of  exhaustion.  During  the  attack  it  will  be  noted 
that  the  surface  and  face  are  normal,  showing  absence  of  respiratory 
embarrassment,  the  breathing  varying  from  very  quiet  to  spluttering 
and  gurgling  sounds,  the  pupils  not  dilated,  the  pulse  normal,  the 
temperature  normal,  and  absence  of  foaming  at  the  mouth  and 
wounding  of  the  tongue. 

The  hysterical  state  is  shown  by  disturbances  of  the  mental  and 
sensory-motor  functions,  respectively.  It  may  be  a  permanent 
condition  or  occur  at  intervals  with  greater  or  less  severity. 

Mental  Disturbances. — The  patients  are  emotional,  erratic,  excit- 
able, impatient,  and  self-important,  showing  marked  defects  of  will 
and  mental  power. 

Sensory  Disturbances. — These  consist  of  either:  (i)  a  condition 
of  exaggerated  sensibiHty  or  hyperesthesia,  as  shown  by  the  marked 


HYSTERIA  621 

effects  from  the  slightest  irritation  and  the  cutaneous  tenderness 
along  the  spine  (the  lower  part  of  the  abdomen,  and  ovarian  region 
are  often  hyperesthetic) ;  or  (2)  a  condition  of  anesthesia,  as  shown 
by  the  apparent  absence  or  recognition  of  pain  after  severe  irritation, 
or  a  perverted  sensibility,  as  shown  by  the  feeling  of  tingling,  numb- 
ness, and  formication.  The  anesthetic  area  is  ischemic.  Sensibility 
to  heat  or  cold  is  often  absent.  There  is  great  perversion  of  the 
special  senses  in  many  of  the  cases.  Severe  pain  at  the  top  of  the 
head,  as  if  a  nail  were  being  driven  in  it,  is  peculiar  to  hysteria  and  is 
termed  clavus. 

Motor  Disturbances. — These  phenomena  embrace  every  variety 
of  motor  disturbance,  from  exaggerated  excitable  movements  to 
defective  or  complete  loss  of  power.  With  the  paralysis  that  may 
occur,  neither  nutrition  nor  sensation  is  constantly  impaired.  Hys- 
terical paralysis  is  liable  to  frequent  and  sudden  changes,  the  loss 
of  power  often  disappearing  suddenly.  Aphonia,  from  paralysis 
of  the  laryngeal  muscles,  is  a  frequent  form  of  paresis.  Some  hyster- 
ical patients  refuse  to  even  make  an  -attempt  at  speech  (mutism) . 
Hysterical  contractures  often  are  most  extensive  and  persistent. 
Under  some  emotion  or  unknown  cause  a  group  or  groups  of  muscles 
contract  abruptly  or  by  degrees,  the  spasms  involving  flexors  or 
extensors  or  both  with  changes  in  reflexes,  and  lasting  for  days  or 
years.     Convulsive  seizures  are  common. 

A  curious  enlargement  of  the  abdomen  is  observed  sometimes, 
constituting  the  so-called  phantom  tumor.  This  region  presents  a 
symmetrical  prominence  in  front,  often  of  large  size,  with  a  con- 
striction below  the  margin  of  the  thorax  and  above  the  pubes.  The 
enlargement  is  quite  smooth  and  uniform,  soft,  very  mobile  as  a 
whole  from  side  to  side,  resonant,  but  variable  on  percussion,  and 
not  painful.  Vaginal  examination  gives  negative  results,  and  under 
anesthesia  the  prominence  immediately  subsides,  returning  again 
as  the  patient  regains  consciousness. 

Among  the  numerous  other  symptoms  that  may  develop  in  a 
hysterical  patient  are  disturbances  of  digestion,  circulation,  and 
respiration,  and  disorders  of  micturition  and  menstruation. 

Among  other  phenomena  that  belong  to  the  hysterical  state  are 
to  be  mentioned  hystero-epilepsy,  a  condition  of  hysteria  to  which  is 
superadded  the  convulsion,  epileptic  in  form;  catalepsy,  a  condition 
in  which  the  will  seems  to  be  cut  off  from  certain  muscles,  and  in 
whatever  position  the  affected  member  is  placed  it  will  so  remain 


622 


HYSTERIA 


for  an  indefinite  time.  There  may  or  may  not  be  unconsciousness 
and  loss  of  sensation;  trance,  the  individual  lying  as  if  dead,  circula- 
tion and  respiration  having  almost  ceased;  ecstasy,  a  condition  in 
which  the  individual  pretends  to  see  visions,  and  acts  in  a  most 
ridiculous  manner. 

Diagnosis. — The  hysterical  state  is  so  general  in  its  manifestations 
that  it  is  to  be  borne  in  mind  in  diagnosing  all  ailments  occurring 
in  women.  The  diagnosis  is  attended  with  great  difficulty,  however, 
and  requires  the  display  of  all  the  skill  of  the  clinician  to  prevent 
error. 

It  is  important,  and  sometimes  difficult,  to  differentiate  hysteria 
and  neurasthenia;  Wheeler  and  Jack's  table  is  useful: 


Neurasthenia 


Hysteria 


1.  Occurs  most  often  in  men 

2.  Usually  directly  attributable  to  overwork 

3.  Little  desire  for  sympathy 

4.  Usually  wasting  is  present ^  .  .  .  . 

5.  Very  amenable  to  proper  treatment 


Women  most  frequently. 

Often  seen  amongst  the  indolent  and 

the  rich. 

Great  desire  for  sympathy. 

Often  plump  or  fat. 

Anything  but  amenable  to  treatment. 


Prognosis. — Death  from  either  a  hysterical  fit  or  the  hysterical 
state  is  the  rarest  of  events,  if  it  ever  occurs.  The  ultimate  recovery 
of  a  hysterical  patient  is  of  frequent  occurrence.  Marriage  has 
cured  many  cases,  although  it  can  hardly  be  advised  by  the  physician. 

Treatment. — For  the  hysterical  attack,  little  need  be  done,  as  a 
rule,  unless  the  paroxysm  is  violent  or  prolonged,  in  which  case 
valerianate  of  ammonium,  Hoffman's  anodyne,  or  aromatic  spirit 
of  ammonia  may  be  administered.  In  severe  cases,  Charcot  recom- 
mends making  firm  pressure  over  the  ovarian  region. 

The  management  of  a  confirmed  case  of  hysteria  will  tax  the  skill 
of  the  most  astute  physician.  It  is  in  connection  with  hysteria 
that  the  peculiar  phenomena  supposed  to  arise  from  applying  differ- 
ent metals  to  the  surface  of  the  body  have  been  noticed. 

Moral  and  hygienic  measures  are  of  the  first  importance  in  the 
management  of  hysterical  patients.  The  treatment  of  hysterical 
patients  by  isolation  is  strongly  urged  by  many  specialists.  Dr. 
S.  Weir  Mitchell  has  devised  a  plan  for  bedfast  hysterical  patients, 
of  massage,  faradization,  and  forced  feeding,  which  has  been  success- 
ful in  a  number  of  cases. 

There  is  no  fixed  therapeutic  treatment  for  hysteria,  the  various 


NEUE  ASTHENIA  623 

symptoms  calling  for  interference  as  they  arise.  It  is  well,  how- 
ever, to  avoid  the  use  of  stimulants,  and  opiates,  chloral,  and  other 
sedatives. 

NEURASTHENIA 

Synonjrms. — Nervous  prostration;  nervous  exhaustion;  the  Ameri- 
can disease. 

Definition. — A  debility  of  the  nervous  system,  causing  an  inability 
or  lessened  desire  to  perform  or  attend  to  the  various  duties  or 
occupations  of  the  individual.     It  is  a  purely  functional  condition. 

Bartholow  describes  it  as  consisting  "essentially  in  an  exaggerated 
susceptibility  to  bodily  impressions  and  false  reasoning  thereon." 

Causes. — Heredity,  neurotic  temperament,  sexual  excesses,  alcohol, 
tobacco,  mental  exertion,  emotion,  overwork,  and  various  chronic 
diseases  are  the  principal  causes.  Men  are  especially  liable  to  the 
affection. 

Symptoms. — Nervous  debility  may  affect  any  organ  of  the  body. 
It  is  a  condition  of  nerve-tire  or  exhaustion,  and  hence  the  nervous 
energy  necessary  for  functional  activity  of  any  particular  organ  may 
be  wanting,  a  fair  example  being  seen  in  cases  of  nervous  dyspepsia. 

One  of  the  earliest  manifestations  of  nervous  exhaustion  is  an 
irritability  or  weakness  of  the  mental  faculties,  as  shown  by  inability 
to  concentrate  the  thoughts,  and  efforts  to  do  so  causing  headache, 
vertigo,  restlessness,  fear,  and  a  feeling  of  weariness  and  depres- 
sion, together  with  an  army  of  symptoms  attendant  on  general 
nervousness. 

There  may  be  ocular  disturbances,  cardiac  palpitation,  coldness 
of  the  hands  and  feet,  and  chilliness  followed  by  flashes  of  heat, 
followed  in  turn  by  slight  sweating.  Patients  are  troubled  with 
insomnia,  or  fatiguing  sleep,  accompanied  with  unpleasant  dreams. 

In  the  male  there  are  genitourinary  disorders,  with  pains  in  the 
back,  giving  the  dread  of  impotence.  In  females,  painful  menstrua- 
tion, ovarian  irritation,  and  irritable  uterus. 

The  "neurasthenic  stigmata"  are:  Feeling  of  pressure  on  head; 
disturbance  of  sleep;  pain  in  back;  muscular  weakness;  dyspepsia; 
sexual  disorders;  and  mental  disturbances. 

Diagnosis. — It  is  of  importance  to  determine  between  a  true  nerv- 
ous exhaustion  and  nervous  debility  the  result  of  organic  disease. 
A  study  of  the  history  of  the  case,  together  with  the  symptoms, 
should  prevent  error. 


624  Raynaud's  disease 

Neurasthenic  symptoms  in  puberty  are  strongly  indicative  of 
mental  instability,  and  great  care  must  be  exercised  to  prevent  actual 
insanity  from  developing. 

For  differentiation  from  hysteria,  see  page  622, 

Prognosis. — Usually  some  mental  weakness  remains  after  re- 
covery from  an  attack  of  neurasthenia. 

Treatment. — The  physician  should  remember  that  neurasthenia 
is  not  a  disease  per  se,  but  that  the  victim  is  a  sick  individual  needing 
the  best  environment,  rest,  and  good  food.  Attention  to  the  secre- 
tions, diet,  and  surroundings,  with  rest  and  diversion  of  the  mind  are 
essential  to  success.  Travel,  short  of  fatigue,  pleasant  companion- 
ship, and  relief  from  responsibility  should  be  advised.  Bathing, 
massage,  and  galvanism  are  important  aids  in  the  management. 
In  anemic  and  weak  individuals  the  rest-cure  proposed  by  Dr.  S. 
Weir  Mitchell  will  be  of  value. 

Among  the  internal  remedies  that  are  of  value  in  this  condition 
may  be  mentioned  arsenic,  strychnine,  valerianate  of  zinc,  phosphorus, 
fluidex  tract  of  coca,  cocoa  wine,  and  the  compound  syrup  of  hypo- 
phosphites.  Quinine  sulphate  in  small  doses,  gr.  j  to  ij  (0.065  to 
0.13  gm.),  daily,  for  weeks,  seems  to  lessen  the  excitability  of  the 
nervous  system.     The  following  is  an  excellent  tonic  in  this  affection : 

I^.     Fluidextract.  cocae f  3ij  8  c.c.' 

Acid,  phosphoric,  dil f  3vj  24  c.c. 

Tinct.  nucis  vomicae f  5ij  8  c.c. 

Syr.  zingiberis f  Bjss  45  c.c. 

Aquae  menth^  pip.  q.  s.  ad.   fSvj           ad  180  c.c. 
M.  S. — Tablespoonful  after  meals,  in  water. 

RAYNAUD'S  DISEASE 

A  very  rare  disease,  characterized  essentially  by  symmetrical  gan- 
grene. The  cause  is  unknown;  but  there  are  three  chief  theories 
brought  forward  to  explain  the  disease.  These  are  that  it  is  due  to 
(i)  endarteritis  obliterans,  (2)  to  peripheral  neuritis,  (3)  to  vascular 
spasm.  The  affection  is  associated  with  some  disturbance  of  the 
vasomotor  system,  as  a  result  of  which  local  stagnation  of  the  per- 
ipheral circulation  occurs.  In  consequence  of  this  there  arise  localized 
anemia,  congestion,  and  finally  gangrene,  symmetrically  distributed. 
The  condition  is  observed  most  often  in  neurotic  women  under 
thirty  years  of  age  and  in  children.  Pain  is  a  prominent  symptom. 
The  treatment  is  unsatisfactory;  the  attacks  continue  but  the  prog- 


OCCUPATION   NEUROSES  625 

nosis  as  to  life  is  favorable.  Local  warmth,  friction,  and  galvanism 
together  with  the  internal  administration  of  tonics  are  indicated. 
Nitroglycerin,  in  doses  of  gr.  ^foo  (0.00065  g"^-),  increased  to  gr. 
^^0  (0.0013  gm.),  three  times  a  day,  has  been  recommended. 

OCCUPATION  NEUROSES 

S5mon3nns. — Professional    neuroses;    artisans'    cramp. 

Varieties. — Writers'  cramp;  piano-players'  cramp;  telegraphists, 
cramp;  violin-players'  cramp;  dancers'  cramp. 

Definition. — A  group  of  affections  of  the  nervous  system,  character- 
ized by  the  occurrence  of  spasm  (cramp)  and  pain  in  groups  of 
muscles,  in  consequence  of  overuse  or  frequently  repeated  muscular 
acts. 

Causes. — Undetermined.  It  has  been  noticed  that  many  persons 
suffering  from  occupation  neuroses  have  a  neurotic  family  history. 

Symptoms. — The  manifestations  of  any  of  the  several  varieties 
of  this  condition  generally  develop  slowly  with  a  sensation  of  stiffness 
in  the  used  member,  the  part  feeling  fatigued  and  heavy,  eventually 
being  incapacitated  for  work  by  the  occurrence  of  spasmodic  con- 
tractions. Attempts  to  move  the  part  produce  pain  and  often  tremor. 
Actual  paralysis  may  be  present.  There  is  often  the  sensation 
of  pricking  and  numbness  in  the  affected  member.  The  electro- 
contractility  is  preserved  until  atrophy  from  non-use  develops. 
Associated  with  the  local  changes  there  are  nervousness,  mental 
worry,   and  often  depression. 

Diagnosis. — The  history  of  the  case  and  its  results  make  the 
diagnosis  easy. 

Prognosis. — The  outlook  is  often  unfavorable.  Treatment  should 
be  long-continued  as  the  prognosis  is  uncertain.  Obstinate  cases  often 
recover  with  persistent  treatment.     Recurrences  are  not  uncommon. 

Treatment. — The  affected  part  should  be  placed  at  absolute  rest. 
General  rest  with  mental  quietude  is  also  beneficial.  The  general 
neurotic  condition  of  the  patient  should  receive  attention.  Locally, 
massage,  friction,  faradism,  and  passive  movements  are  very  effica- 
cious.    The  following  combination  has  been  employed  with  success: 

I^.     Zinci  phosphidi gr.  ij  0.13  gm. 

Ext.  nucis  vomicae; gr.  x  0.6    gm. 

Ferri  albuminat gr.  xxx  2 .  o    gm. 

M.     Ft.  pil.  No.  xxx. 

S. — One  after  meals. 
40 


626  '  PAEALYSIS   AGITANS 

PARALYSIS  AGITANS 

Synonyms. — Shaking  palsy;  Parkinson's  disease. 

Definition. — A  nervous  disease  of  unknown  pathology,  charac- 
terized by  tremors,  progressive  loss  of  power  in  the  affected  muscles, 
moderate  rigidity,  with  alterations  in  the  gait,  and  at  times  mental 
impairment. 

Cause. — Age  seems  to  be  an  etiological  factor,  most  cases  develop- 
ing after  fifty  years.     It  is  most  frequent  in  women. 

Pathological  Anatomy. — No  characteristic  lesion  has  as  yet  been 
determined.  It  being  a  disease  of  past  middle  life,  there  is  probably 
an  interstitial  hyperplasia  of  some  layer  of  the  cortex  from  altera- 
tions in  the  intima  of  the  vessels. 

Symptoms. — The  onset  is  gradual,  the  tremor  beginning  in  one  of 
the  extremities,  most  often  the  hand  and  forearm.  At  first  it  can 
be  controlled  by  the  will,  for  a  time  at  least,  and  is  suspended  by 
voluntary  movement.  The  disease  gradually  extends  until  an 
entire  side  or  the  upper  or  lower  limbs  is  involved.  The  face  and 
head  rarely  present  tremors,  but  are  not  exempt.  Facial  expression 
is  lost  and  speech  is  slow  and  somewhat  measured.  A  peculiar 
rigidity  of  the  affected  muscles  is  characteristic  of  the  advanced 
stage.  "At  this  stage  of  the  disease  the  hands  are  apt  to  assume  the 
so-called  bread-crumbling  position,  i.e.,  the  thumb  and  the  fingers 
approximate  and  move  restlessly  over  one  another,  as  in  the  act  of 
crumbling  bread.  There  is  often  a  tendency  on  the  patient's  part 
to  go  forward — so-called  propulsion — and  this  is  sometimes  so  marked 
that  if  the  patient  is  once  started  in  a  walk  forward,  his  gait  becomes 
more  and  more  rapid,  and  he  cannot  stop  himself"  (Gray).  The 
patients  are  usually  restless  and  annoyed  with  insomnia.  The 
general  health  is  fair.  The  mind  is  generally  retained,  although 
melancholia  and  mild  dementia  have  been  noted  in  a  few  cases. 

Diagnosis. — Disseminated  sclerosis  has  a  tremor,  but  only  on 
voluntary  movements — intention  tremor.  There  is  also  scanning 
speech  and  ataxic  gait,  with  mental  enfeeblement,  as  shown  by  an 
unnatural  contentment  with  the  physical  condition  and  surroundings. 

Chorea  possesses  a  tremor,  but  the  movements  are  general,  and 
particularly  involve  the  muscles  of  the  face.  Again,  chorea  is  a 
disease  of  children  and  young   adults. 

Prognosis. — Complete  recovery  is  very  rare.  Improvement  often 
results  from  early  treatment.  The  disease  does  not  tend  to  shorten 
life,  but  its  course  is  indefinite. 


MENTAL   DISEASES  627 

Treatment. — Physical  and  mental  rest  are  necessary  in  all  cases. 
Nutritious  diet,  cod-liver  oil,  hypophosphites,  arsenic,  and  iron  are 
necessary  to  restore  and  maintain  the  general  health.  Friction, 
massage,  bathing,  galvanism,  and  specially  arranged  gymnastics 
are  of  great  value  in  this  condition.  Drugs  such  as  hyoscy amine 
sulphate,  gr.  }io  to  Ho  (0.002  to  0.006  gm.),  three  times  daily,  and 
hyoscine  hydrobromide,  gr.  3'^oo  "to  Hoo  (0.00032  to  0.00065  gm.), 
three  times  daily,  are  often  of  benefit. 

MENTAL  DISEASES 

General  Considerations. — An  hallucination  is  a  state  of  the  mind 
in  which  the  patient  believes  he  perceives  external  objects  that  do 
not  exist,  or  in  other  words  is  a  condition  of  false  perception  occurring 
independent  of  external  impressions. 

An  illusion  is  a  perverted  impression  based  upon  an  actual 
perception. 

A  delusion  is  a  faulty  belief  concerning  a  subject  capable  of  physical 
demonstration,  out  of  which  the  patient  cannot  be  reasoned  by 
adequate  methods  for  the  time  being  (H.  C.  Wood). 

A  lucid  interval  (in  insanity)  is  a  period  in  which  there  is  a  tem- 
porary cessation  of  the  insanity,  or  a  complete  restoration  to  reason. 

Delirium  is  a  condition  of  mental  aberration  characterized  by  an 
apparent  exaltation  of  all  the  processes  of  the  mind  manifested  by 
mental  irritation  and  confusion,  transitory  delusions,  and  fleeting 
hallucinations,  and  by  disordered,  senseless  speech,  and  by  motor 
unrest.  It  may  be  a  part  of  mania,  hysteria,  or  acute  mania,  or  it 
may  be  secondary  to  some  toxic  condition  such  as  accompanies 
uremia,  infectious  fevers,  alcoholism,  etc. 

Definitions  of  Insanity. — There  is  no  satisfactory  definition  of 
insanity. 

According  to  Taylor,  the  term  insanity  ib  applied  to  "those  states 
of  disordered  mind  in  which  a  person  loses  the  power  of  regulating 
his  actions  and  conduct  according  to  the  ordinary  rules  of  society. 
In  all  cases  of  real  insanity  the  intellect  is  more  or  less  affected." 

Insanity  is  defined,  in  Allbutt's  System  of  Medicine,  as  "such  a 
disorder  or  disease  of  the  nervous  system  as  prevents  the  individual 
from  reacting  normally  as  a  member  of  the  society  to  which  by  birth 
and  education  he  belongs." 

For  other  definitions  see  page  632. 


628 


"MENTAL   DISEASES 


Classification  of  Insanity. — This  is  as  unsatisfactory  as  the 
definitions.  Most  of  the  classifications  are  mystifying  and  incom- 
prehensible to  the  general  practitioner.  One  of  the  most  in- 
telligible is  herewith  appended: 


\.      Psychical  Disease  of  the 
Developed  Brain. 
I.  Functional  neuroses  or  dis- 
eases without  a  pathological 
basis. 

(i)   Melancholia     (inhibition 
of  mental  action). 

a.  Melancholia  simplex, 

b.  Melancholia  cum  stu- 
pore. 

(2)  Mania. 

a.  Mania  with  exaltation. 
h.  Mania  with  frenzy. 

(3)  Confusional  insanity,  or 

primary  dementia. 

(4)  Stuporous  insanity. 

(5)  Secondary  dementia. 

a.  With  agitation. 

b.  With  apathy. 

II.  Psychical  degenerations, 
that  is,  diseased  conditions 
of  the  developed  brain,  in- 
herited or  acquired, 
(i)  Constitutional  affective 
insanity  (folie  raison- 
nante). 

Moral  insanity. 
Impiilsive  insanity. 
Transitory  mania. 
Kleptomania. 
Pyromania. 
Dipsomania. 
Homicidal  mania. 
Suicidal  mania, 
(2)  Paranoia. 

a.  Primary, 

b.  Acquired. 

I.   Typical       form 
(with      delusions 


of        persecution 
and      grandeur) . 

2.  Questioning  par- 
anoia. 

3.  Religious  para- 
noia. 

4.  Erotic  paranoia 
(sexual  perver- 
sion) . 

(3)  Periodical     insanity — cir- 
cular insanity. 

(4)  Insanity    from     constitu- 
tional neuroses. 

a.  Neurasthenic  insanity. 

Agoraphobia. 
Claustrophobia. 
Aerophobia. 
Zoophobia. 

b.  Epileptic  insanity.    . 

c.  Hysterical  insanity. 

d.  Hypochondriacal  in- 
sanity. 

III.  Cerebral    disease    with    con- 
stant   pathological    changes, 
or  organic  psychoses, 
(i)  Acute  delirium. 

(2)  General    paresis    (demen- 
tia paralytica). 

(3)  Syphilitic  insanity. 

(4)  Alcoholic  insanity. 

(5)  Senile  insanity. 

B.     Arrested     Cerebral     De- 
velopment. 
(i)  Idiocy. 

a.  With  predominant  in- 
tellectual defect. 

b.  With  predominant 
ethical  defect  (pri- 
mary moral  weakness). 

(2)   Cretinism. 


MELANCHOLIA  629 

Idiocy  differs  from  other  states  of  insanity  in  the  fact  that  it  is 
marked  by  a  congenital  deficiency  of  the  mental  faculties.  There 
is  not  here  a  perversion  or  a  loss  of  what  has  once  been  acquired,  but 
a  state  in  which,  from  defective  structure  of  the  brain,  the  individual 
has  never  been  able  to  acquire  any  degree  of  intellectual  power  to 
fit  him  for  his  social  position.  It  commences  with  life  and  continues 
through   it    (Taylor). 

MELANCHOLIA 


Synonyms. — Depression  of  spirits;  psychalgia. 

Definition. — A  variety  of  mental  alienation,  characterized  by 
more  or  less  profound  depression,  with  either  no  marked  intellectual 
disturbance  or  the  presence  of  more  or  less  incoherence,  and  hallu- 
cinations and  delusions.  The  cerebral  mechanism  develops  a  con- 
dition of  supersensitiveness,  all  impressions  being  exaggerated,  and 
a  state  of  abnormal  self-consciousness  existing. 

Varieties. — Melancholia  simplex;  hallucinatory  melancholia,  mel- 
ancholia agitata;  melancholia  attonita;  hypochondriac  melancholia; 
chronic  melancholia;  senile  melancholia. 

Causes. — Heredity,  failing  health,  grief,  domestic  and  financial 
worries,  neurasthenia,  menstrual  irregularities,  pregnancy,  child- 
birth, lactation,  climacteric,  gastrointestinal  disorders,  alcoholic  and 
sexual  excesses,  and  organic  brain  disease  may  be  mentioned  as 
causes.  Religion  rarely  causes  this  form  of  insanity  although  it 
frequently  lends  color  to  it.  It  is  most  frequent  in  women  and  in 
the  young.  Attacks  of  melancholia  are  more  frequent  in  the  spring 
and  early  summer  months  and  statistics  show  that  suicides  also  are 
more  frequent  during  these  periods. 

Pathology. — The  alterations  in  the  nerve  structure,  underlying 
an  attack  of  melancholia,  are  undetermined.  Anemia  and  sluggish 
nervous  energy  are  constant  phenomena,  but  are  hardly  the  only 
conditions  disturbing  the  cortex. 

Symptoms. — Melancholia  may  be  the  initial  stage  of  a  mania, 
delusional  insanity,  or  paretic  dementia,  or  a  stage  of  folie  circulaire. 

Mental. — The  cardinal  condition  is  a  feeling  of  depression,  misery, 

or  mental  anguish  or  pain,  for  which  no  adequate  cause  may  exist. 

The  on^etis  usually  gradual,  with  a  disposition  to  neglect  duties  and 

,iSteif,rthe  patient  worrying  over  a  something  he  cannot  explain.     The 


630  MELANCHOLIA 

world  is  dark  and  gloomy;  and  the  patient  has  a  foreboding  of  some 
awful  calamity  that  is  to  affect  or  wreck  him  or  his  family.  Suspi- 
cion, distrust,  and  often  fear  of  wife,  children,  relatives,  or  friends 
are  common.  Insomnia  is  a  constant  and  stubborn  symptom.  The 
memory  is  maintained,  and  the  reasoning  faculties  are  usually  intact. 
The  patient  may  sit  quietly,  declining  or  unable  to  talk  (silent 
melancholia,  or  mutism),  or  be  restless,  according  to  the  character 
of  the  emotions  affected. 

Physical. — The  patient  presents  either  an  anxious  or  a  woebegone 
expression.  Headache,  particularly  a  post-cervical  ache,  is  a  very 
constant  symptom.  The  skin  is  dry  and  harsh,  the  respirations 
superficial,  the  cardiac  action  slow  and  feeble  and  there  are  gastric 
catarrh,  constipation,  and  scanty,  high-colored  urine.  The  tongue 
is  flabby  and  coated,  and  the  appetite  is  poor.  The  refusal  to  take 
food  is  most  characteristic. 

Hallucinatory  melancholia  is  an  aggravated  form  of  the  disease  in 
which  in  addition  to  the  painful  mental  reflexes,  there  are  distressing 
hallucinations  and  illusions,  the  patient  living  in  a  realm  of  terror. 
The  attack  may  be  the  result  of  a  delusion,  but  much  more  frequently 
the  depression  and  foreboding  give  rise  to  the  delusion.  The  delu- 
sions of  melancholia  are  usually  of  self -accusation,  self-abasement, 
and  justified  persecution;  the  patient  feels  that  he  is  being  punished 
for  some  transgression,  imaginary  or  otherwise. 

The  manias  of  persecution  and  the  monomanias  of  suspicion  are 
all  of  a  melancholic  type,  the  result  of  painful  hallucinations. 

Hypochondriac  melancholia  shows  all  subjective  impressions  with 
disturbed  memory,  leading  to  the  belief  that  the  bowels  have  been 
removed,  food  cannot  be  digested,  that  the  brain  has  turned  around, 
that  the  blood  cannot  circulate,  and  that  gallons  of  blood  have  been 
drawn  from  the  body.  These  distressed  individuals  are  often  con- 
scious of  every  organ  of  the  body  and  experience  disagreeable  im- 
pressions coming  from  them  all,  and  as  a  consequence  are  irritable, 
fretful,  and  exacting.  It  is  to  be  remembered  that  not  uncommonly 
these  patients  really  have  an  organic  disease  affording  a  foundation 
for  the  delusions. 

Melancholia  agitata  is  that  variety  characterized  by  continual 
agitation,  in  which  the  fearful  and  distressful  thoughts  and  imagina- 
tions cause  wringing  of  the  hands,  restless  walking,  rhythmic  swaying 
of  the  body,  and  prayers  beseeching  help,  with  tears  flowing  down 
their  cheeks,  crying  out  for  assistance  and  protection.     Incoherent 


MELANCHOLIA  63 1 

and  violent  impulses  are  frequent,  the  excitement  often  resembling 
an  attack  of  mania. 

Melancholia  attonita,  or  melancholia  with  stupor,  is  marked  by 
the  patients  seeming  to  be  overwhelmed,  sitting  mute,  motionless, 
and  expressionless,  refusing  to  assist  themselves  in  any  way,  and 
often  requiring  mechanical  feeding.  Memory  is  usually  impaired 
in  this  variety,  and  attacks  of  violence  may  occur. 

Chronic  melancholia  is  the  continuation  of  the  depression  over  a 
long  period,  the  individual  living  in  the  fear  of  impending  danger  or 
punishment  for  supposed  acts,  for  long  periods  of  time,  often  with 
apparent  lucid  periods. 

Senile  melancholia  is  a  condition  of  extreme  mental  distress  associ- 
ated with  beginning  senile  dementia. 

Suicidal  impulses  are  present  in  a  fair  proportion  of  cases  of 
melancholia,  and  unless  there  is  everlasting  vigilance  the  patient  will 
succeed  in  his  insane  desire. 

Diagnosis. — The  cases  of  simple  melancholia  are  readily  deter- 
mined. Melancholia  agitata  is  frequently  mistaken  for  acute  mania. 
Melancholia  attonita  closely  resembles  acute  dementia — a  condition, 
it  is  but  fair  to  mention,  denied  by  many  alienists. 

Prognosis. — A  typical  attack  of  melancholia  runs  a  definite  course, 
not  unlike  the  typical  course  of  a  fever.  It  is  favorable  in  the  mild 
cases  of  all  forms  not  associated  with  organic  disease,  and  in  those 
who  have  not  reached  the  climacteric.  Delusional  melancholia  has 
the  most  unfavorable  prognosis.  Pronounced  cases  of  melancholia 
attonita  are  more  apt  to  terminate  in  dementia  than  any  other 
variety. 

Treatment. — Change  of  environment  and  rest  are  essential. 
Attention  to  the  gastrointestinal  canal  is  of  the  greatest  importance, 
as  the  dyspepsia  and  constipation  of  melancholic  patients  form  a 
barrier  to  their  recovery.  Frequent  bathing,  with  friction  to  the 
surface,  aids  in  the  eliminative  action  of  the  skin.  The  diet  must  be 
of  the  most  nutritious  character.  If  food  is  persistently  refused, 
mechanical  feeding  must  be  practised.  The  late  Dr.  Gray  was  a 
strong  advocate  of  small  doses  of  opium,  or  morphine,  in  acute 
melancholia,  and  in  properly  selected  cases  it  is  a  most  valuable 
agent.  Tincture  of  quebracho,  5j  to  ij  (4  to  8  gm.),  well  diluted, 
three  times  daily,  is  often  a  valuable  remedy.  If  the  arterial  tension 
is  relaxed,  good  results  follow  the  use  of  digitalis.  Sodium  phosphate 
is  often  useful. 


632  •  MANIA 

Many  cases  of  melancholia  seem  to  be  due  to  a  brain  fatigue  and 
if  the  patient  can  be  given  many  hours'  sleep  in  the  early  days  of  the 
attack  recovery  is  assured.  In  melancholia  attonita,  excellent  re- 
sults often  follow  the  use  of  cannabis  indica  in  increasing  doses. 
Such  tonics  as  quinine,  arsenic,  and  strychnine  are  of  value  in  build- 
ing up  the  patient  and  as  the  strength  improves  open-air  exercise 
must  be  employed.  Insomnia  must  be  combated  by  evening  bathing 
and  feeding  and  by  the  use  of  chloral,  sulphonal,  trional,  or  hyoscine. 

MANIA 

Synonyms. — Insanity;  madness. 

Definition. — An  intense  mental  exaltation,  with  great  excitement, 
loss  of  self-control,  with,  at  times,  absolute  incoherence  of  speech, 
and  loss  of  consciousness  and  memory  (Clouston). 

Mania  is  a  condition  characterized  by  an  abnormal  exaltation  and 
activity  of  the  mental  functions — the  intellectual  faculties,  the 
emotions,  and  the  will — and  may  show  itself  by  irrational  talking 
and  acting,  by  delusions,  illusions,  and  hallucinations,  and  by  un- 
usual muscular  activity  or  movements  (Chapin). 

A  mental  condition  in  w^hich  there  is  an  emotional  exaltation, 
accompanied  by  illusions,  hallucinations,  delusions,  great  mental  and 
physical  excitement,  and  a  complete  loss  of  the  inhibitory  power  of 
the  will;  in  acute  cases,  and  frequently  in  chronic  forms  of  the  disease, 
there  is  marked  destructiveness  and  a  tendency  to  violence  (Wood). 

An  attack  of  mania  may  be  acute,  subacute,  or  chronic. 

Causes. — Infiammation  or  other  organic  disease  of  the  brain  or 
its  membranes,  mental  shock  or  strain,  domestic,  moral,  or  financial 
worry,  excesses  of  various  kinds,  ovarian  disease,  menstrual  disorders, 
climacteric  in  neurotic  individuals,  pregnancy,  parturition,  lactation, 
anemia,  alcoholism,  syphilis,  and  hereditary  predisposition  are  the 
most  frequent  causes. 

Pathology. — There  are  no  constant  morbid  changes  associated 
with  mania.  In  all  varieties  of  acute  insanity  there  exists  vitiated 
nervous  energy  or  impaired  vitality,  the  result  of  overexcitement  or 
overstimulation,  motor  disturbance,  or  autoinfection,  due  to  the 
imperfect  elimination  of  the  products  of  tissue-waste.  If  death  fol- 
lows the  acute  symptoms,  the  vessels  of  the  brain  and  membranes 
are  engorged,  but  in  the  majority  of  instances  the  brain  structure 
is  normal. 


MANIA  67,^ 

If  death  occurs  in  chronic  mania,  the  most  frequent  change  found 
will  be  thickened  and  adherent  dura  mater.  Any  form  of  organic 
change  may  be  found  post-mortem  in  those  dying  of  any  form  of 
mania. 

"There  is  no  reason  why  mere  dynamic  brain  disturbance  should 
not  kill  and  leave  no  structural  trace,  any  more  than  that  it  should 
for  months  abolish  judgment,  affection,  and  memory,  and  then  pass 
off  and  leave  the  brain  and  all  its  functions  intact  (Clouston). 

Symptoms.  Acute  Mania. — The  onset  may  be  abrupt,  or  follow 
a  period  of  emotional  depression,  associated  with  lassitude,  feeling 
of  unrest,  disinclination  to  work,  and  disorders  of  the  gastrointestinal 
canal,  with  insomnia  and  an  introspection;  these  syrnptoms  consti- 
tute the  melancholic  stage  of  mania. 

The  maniacal  stage  is  characterized  by  loud  talking,  intense  ego- 
tism, violent  motions  of  the  limbs  and  body,  great  restlessness,  and 
excitement;  the  thoughts  flow  with  wonderful  freedom  and  amazing 
rapidity,  the  condition  often  resembling  the  symptoms  of  early 
alcoholic  intoxication;  as  the  exaltation  continues  the  patient  be- 
comes either  sullen,  irritable,  and  angry,  offering  violence  to  those 
around  him,  or  he  becomes  garrulous,  talking  of  his  personal  affairs, 
is  confidential  and  communicative  to  strangers,  often  making  egotis- 
tic offers,  passing  frequently  into  incoherence  of  language  and  action. 
Sexual  passions  are  frequently  exalted  and  acts  of  masturbation 
practised,  with  outbreaks  of  vulgar,  obscene,  and  profane  language, 
which  is  entirely  foreign  to  the  individual  in  mental  health.  Delu- 
sions are  an  almost  constant  symptom,  of  a  superficial  or  transitory 
character,  changing  with  every  new  appearing  mood.  The  mani- 
acal patient  is  sleepless,  or  may  have  short  naps,  at  once  continuing 
his  chatter  on  awakening. 

Any  attack  may  show  all  of  the  symptoms  mentioned,  or  any  one 
or  more  of  them,  but  the  great  majority  of  cases  show  intense  egotism, 
loud  talking,  violent  motion  of  limbs  or  body,  hurry,  excitement,  insomnia, 
incoherence,  and  incessant  noise. 

The  course  of  an  attack  shows  periods  of  remissions  and  exacerba- 
tions with  nocturnal  crises;  loss  of  flesh  and  mental  weakness  are 
often  marked  as  the  attack  progresses. 

Acute  delirious  mania,  typhomania,  is  a  psychosis  of  sudden  onset, 
attended  with  increased  bodily  temperature,  dry  tongue,  quick, 
feeble  pulse,  scanty  urine,  and  marked  by  delirium  with  sensuous 
hallucinations,   marked   incoherence,   restlessness,   refusal   of   food, 


634  MANIA 

loss  of  memory,  and  rapid  bodily  wasting,  terminating  frequently 
in  death. 

Amenorrheal  mania  consists  of  attacks  of  mania  occurring  at  the 
menstrual  epoch.  Homicidal,  suicidal,  and  various  hysterical  im- 
pulses are  frequent. 

Mania-a-potu  is  an  attack  of  acute  delirium,  due  to  alcoholic 
excesses  in  those  engaged  in  a  sudden  debauch,  or  who  have  drunk 
heavily  and  eaten  little,  for  a  comparatively  short  period. 

Asthenic  mania  is  that  form  in  which  there  is  general  anemia 
associated  with  neurasthenic  symptoms. 

Dancing  mania  is  an  hysterical  mental  state  in  which,  through 
sympathy  and  imitation,  dancing  of  a  most  grotesque  and  extrava- 
gant character  occurs.     It  is  usually  epidemic. 

Delusional  mania  is  the  result  of  fixed  delusions,  either  causing 
or  associated  with,  the  maniacal  outbreak. 

Erotic  mania,  erotomania,  presents  systematized  delusions  of  an 
erotic  character,  not  necessarily  accompanied  by  sexual  desire. 

Nymphomania  is  a  morbid,  irresistible  impulse  to  satisfy  the  sexual 
appetite,  and  is  peculiar  to  the  female  sex. 

Epileptic  mania  follows  an  epileptic  paroxysm,  and  is  often  of  a 
most  violent  kind,  the  maniacal  acts  being  of  the  most  treacherous 
and  malicious  character. 

Hallucinatory  mania  presents  visual,  auditory,  olfactory,  and  other 
sense  hallucinations. 

Homicidal  mania  is  any  variety  of  mental  disease  in  which  there  is  a 
desire  or  an  attempt  on  the  part  of  the  patient  to  commit  murder. 
The  condition  may  be  the  result  of  delusions  that  the  persons  attacked 
either  are  persecuting  or  going  to  kill  the  patient,  or  of  the  excessive 
excitement  that  vents  itself  in  destructiveness,  combativeness,  or 
desire  to  kill;  or  there  may  be  a  morbid  desire,  impulse,  or  craving 
to  do  murder ;  or  the  homicidal  act  may  be  unconsciously  done  during 
an  acute  delirium,  or  a  paretic  or  epileptic  maniacal  impulse.  In 
cases  of  murder  the  question  of  responsibility,  or  the  difference 
between  the  insane  criminal  and  the  criminal  is  not  always  readily 
determined.  With  insane  criminals,  in  the  act  itself  lies  the  satisfac- 
tion and  not  the  object,  while  with  criminals  the  act  is  only  a  means 
to  an  end;  to  the  former,  crime  is  a  pleasure,  to  the  latter  a  paying 
business,  necessitating,  it  may  be,  disagreeable  or  horrible  acts. 

Morphinomania  is  the  insane  craving  for  the  stimulating  action  of 
morphine — a  moral  insanity. 


MANIA  635 

Puerperal  mania  is  the  maniacal  outbreak  as  seen  in  the  puerperal 
woman.  This  is  now  thought  to  be  of  separate  origin,  although 
the  mental  strain  through  which  the  female  has  been  passing  is  a  pre- 
disposing factor  in  those  who  have  a  neurotic  history. 

Transitory  mania,  or  ephemeral  mania,  is  a  rare  form  of  maniacal 
excitement  of  sudden  onset,  violent  and  decided  in  character,  accom- 
panied by  great  insomnia,  incoherence,  and  more  or  less  complete 
unconsciousness  of  familiar  surroundings.  The  attack  as  suddenly 
terminates,  the  duration  being  from  a  few  hours  to  a  few  days. 

Senile  mania  is  the  mental  exaltation  occurring  in  persons  with 
senile  arterial  changes  or  senile  cerebral  atrophy.  It  is  soon  followed 
by  dementia. 

Recurrent  mania,  or  chronic  mania  with  lucid  intervals  of  longer  or 
shorter  duration.     This  is  generally  of  alcoholic  origin. 

A  maniacal  outbreak  may  present  any  one  or  a  number  of  the 
varieties  named. 

Chronic  Mania. — A  condition  of  continual  mental  exaltation,  the 
acute  symptoms  having  continued  in  a  chronic  course.  The  line  that 
distinguishes  between  an  acute  and  a  chronic  mania  must  always  be 
somewhat  arbitrary  and  unscientific.  The  duration  of  the  mania 
beyond  twelve  months  is  usually  considered  sufficient  to  determine 
the  condition,  and  this  is  well,  since  it  precludes  the  possibility  of 
terming  the  condition  incurable.  If  the  term  chronic  mania  was 
restricted  to  those  cases  in  which,  between  the  exacerbations  of  rest- 
lessness, excitement,  and  destructiveness,  were  evidences  of  dementia, 
less  confusion  would  occur. 

Tenninations  of  Mania. — About  50  per  cent,  of  acute  manias,  not 
due  to  organic  disease,  recover  after  periods  varying  from  one  month 
to  several  years.  A  fair  proportion  of  cases  make  a  partial  recovery 
and  are  able  to  return  to  their  work,  but  always  showing  some  altera- 
tion in  character  or  affection,  or  some  eccentricity,  or  a  slight  mental 
weakness.  About  20  per  cent,  of  cases  terminate  in  dementia  or 
mental  death  and  this  is  always  the  fear  in  each  case.  Two  per  cent. 
of  cases  die,  either  the  result  of  exhaustion  or  from  the  organic  condi- 
tion causing  or  associated  with  the  attack. 

Prognosis. — The  question  of  recovery,  partial  or  complete,  is 
always  difficult  to  determine,  depending  upon  the  cause,  tempera- 
ment, disposition,  education,  nationality,  and  the  normal  mentality 
of  the  individual.  Recovery  is  usually  gradual;  rarely  sudden  res- 
toration occurs. 


636  •  MANIA  •     ^ 

Favorable  indications  are:  Sudden  onset,  short  duration,  youth  of 
patient,  absence  of  fixed  delusions,  good  appetite,  increasing  hours  of 
sleep ;  moderate  or  no  increase  in  temperature,  pulse,  and  respiration; 
no  evidences  of  mental  weakness,  no  paralysis  or  alteration  of  pupils 
or  articulation,  no  epilepsy,  no  unconsciousness  to  the  calls  of  nature, 
and  no  former  attacks.  Unfavorable  indications  are  the  opposite 
of  these,  the  presence  of  organic  brain  disease,  a  strong  hereditary 
tendency,  and  the  possession  of  an  excitable  disposition  or  nervous 
diathesis. 

Treatment. — The  indications  for  treatment  are  to  quiet  the  exalted 
mentality  and  to  promote  the  constructive  metamorphosis.  Every 
means  should  be  used  to  lessen  the  excitement  of  the  patient  and  pro- 
duce refreshing  sleep.  A  hot  or  warm  bath  is  frequently  one  of  the 
most  soothing  means  of  reducing  excitement;  changing  the  environ- 
ment of  the  patient  and  placing  him  under  the  care  of  a  good,  firm,  but 
kind  and  intelligent  nurse  is  of  importance;  the  society  of  the  family 
or  friends  must  be  forbidden,  for  visits  act  as  stimulants  to  the  dis- 
ordered intellect  and  encourage  discussion  on  the  part  of  the  patient 
as  to  the  character  of  the  treatment,  and  thus  reduce  the  discipline 
so  essential  to  early  recovery. 

If  means  of  this  character  are  unavailing,  and,  unfortunately,  in 
the  majority  of  attacks  they  will  be,  then  resort  must  be  had  to  seda- 
tives, for  every  day's  continuance  of  the  maniacal  outbreaks  lessens 
the  chances  of  restoration.  Hyoscine  hydrobromide,  gr.  3^20  to  Ko 
(0.00032  to  0.00 1  gm.),  repeated  two  or  three  times  daily,  watching 
its  effect  on  the  pupils;  sulphonal,  gr.  xx  (1.3  gm.),  repeated  with 
caution;  chloralamide,gr.  xxx  toxl  (2to  2.6  gm.),  repeated  three  or  four 
times  daily;  and  trional,  gr.  xxx  (2  gm.),  repeated  in  two  or  four  hours, 
are  of  great  value  in  this  connection.  The  latter  is  one  of  the  most 
reliable  drugs  for  relieving  maniacal  excitement  and  insomnia.  Tinc- 
ture of  passion  flower  (passifiora  incarnata),  5j  to  5ij  (4  "to  8  c.c), 
several  times  daily,  may  also  be  used.  When  there  is  much  excite- 
ment and  the  pulse  is  weak,  full  doses  of  the  bromides  and  digitalis 
are  of  benefit.  If  the  muscular  excitement  is  pronounced,  good  re- 
sults follow  the  use  of  morphine  sulphate,  hypodermically,  alone  or 
combined  with  either  atropine  sulphate,  hyoscine  hydrobromide,  or 
duboisine  sulphate. 

In  attacks  of  acute  mania  with  flushed  face,  throbbing  arteries, 
full  pulse,  and  delirious  excitement,  fiuidextract  of  gelsemium,  TTlij 
(0.12  c.c),  every  hour  until  dilatation  of  the  pupils  and  ptosis  develop 


EPILEPTIC   INSANITY  637 

or  until  improvement  occurs,  is  indicated.  Tincture  of  veratrum 
viride,  T([x  (0.65  c.c),  is  also  useful  under  such  circumstances. 

Ice  or  cold  to  the  head  is  likewise  beneficial  in  cases  with  flushed 
face  and  throbbing  temporals.  Post-epileptic  excitement  is  best 
controlled  by  large  doses  of  chloral  given  by  mouth  or  rectum. 

The  general  condition  of  the  patient  calls  for  the  most  prompt 
and  efficient  treatment.  Attention  to  the  gastrointestinal  canal 
and  kidneys  is  of  paramount  importance,  as  many  attacks  of  mania 
are  the  result  of  autointoxication  from  the  retention  of  the  products 
of  mal-assimilation  and  tissue-waste.  The  diet  should  be  of  the 
most  nutritious  character,  peptonized  or  hot  milk,  hot  broths,  eggs, 
and  often  alcoholic  or  malt  liquors,  administered  at  frequent  intervals. 

Patients  not  infrequently  refuse  food  on  account  of  lack  of  appe- 
tite, abhorrence  of  food,  or  from  fear  of  poisoning,  when  recourse 
must  be  had  to  the  stomach  tube,  or  nutritive  enemata.  If  the 
breath  is  heavy,  the  tongue  badly  coated,  the  bowels  costive,  and  the 
skin  sallow,  the  very  best  results  follow  washing  out  the  stomach,  pro- 
viding the  maniacal  condition  permits.  Tonics  are  of  great  value,  a 
combination  like  the  following  always  being  beneficial : 

^.     Quininas  sulphat gr.  xlviij  3 .  i       gm. 

Strychninse  sulphat gr.  ss  o .  032  gm. 

Acid,  hydrochlor.  dil f 5iij  12.0       c.c. 

Aquae  chloroformi f  §iij  90 .  o      c.c. 

Aquae  menthae  pip.  q.  s.  ad  fSvj       ad     180..0      c.c. 
M.   S. — Dessertspoonful,   diluted,   every  four  or  six  hours. 

The  question  of  removal  to  a  hospital  for  the  insane  arises  in 
nearly  all  cases,  and  should  probably  be  answered,  in  the  vast  major- 
ity of  instances,  in  the  affirmative;  as  the  discipline,  regular  hours, 
and  order  of  a  well-managed  hospital  for  the  insane  have  a  most 
remarkable  effect  on  the  majority  of  patients. 

EPILEPTIC  INSANITY 

Definition. — A  mental  condition  caused  by,  or  the  result  of,  epilepsy. 

Causes. — The  careful  study  of  the  brain  of  those  having  epileptic 
insanity  has  failed  to  determine  why  some  epileptics  suffer  from"  any 
of  the  insanities  and  others  have  their  normal  mentality,  and  yet 
others  are  better  after  a  convulsion. 

Varieties. — Pre-epileptic  mania;  post-epileptic  mania;  dementia 
epileptica;  imbecility  with  epilepsy. 


638  EPILEPTIC   INSANITY 

Symptoms. — The  mental  changes  constituting  epileptic  insanity, 
save  in  the  cases  of  epilepsy  with  imbecility  or  idiocy,  develop  after 
some  years  of  the  ordinary  epileptic  paroxysms. 

Pre-epileptic  mania  consists  in  attacks  of  mania  some  days  or 
hours  preceding  the  epileptic  convulsion.  The  patient  is  morose, 
irritable,  and  threatening,  often  making  homicidal  attacks  on  those 
around  him,  friends  or  foes.  Rarely  the  epileptic  seizure  is  replaced 
by  various  insane  or  so-called  hysterical  acts,  as  fits  of  dancing,  laugh- 
ing, crying,  screaming,  swearing,  or  scolding. 

Post-epileptic  mania  follows  the  epileptic  paroxysm,  either  taking 
the  place  of  the  comatose  state  or  following  it.  The  maniacal  acts 
during  these  outbreaks  are  often  of  the  most  desperate  and  impulsive 
character,  many  an  asylum  physician  and  attendant  carrying  scars 
the  result  of  attacks  of  post-epileptic  maniacs. 

Epileptic  dementia  is  the  terminal  mental  obliquity  resulting  in 
about  30  per  cent,  of  insane  epileptics  who  do  not  succumb  previously 
to  nephritis  or  tuberculosis. 

Epileptic  imbecility  is  a  congenital  condition  in  which  epilepsy 
and  imbecility  are  associated. 

Prognosis. — The  great  majority  of  persons  suffering  from  epileptic 
insanity  develop,  sooner  or  later,  either  nephritis  or  tuberculosis. 
Recovery  from  epileptic  mania  is  a  rare  occurrence.  Thirty  per  cent, 
of  epileptic  maniacs  progress  to  dementia  in  from  five  to  ten  years. 

Treatment. — There  is  no  doubt  but  that  full  doses  of  the  bromides 
lessen  the  severity  and  frequency  of  the  paroxysms.  If  the  attack 
can  be  anticipated,  it  may  sometimes  be  averted  by  an  enema  of 
chloral,  gr.  xx  to  xxx  (1.3  to  2  gm.),  or  chloralamide,  gr.  xl  to  Ix 
(2.6to4gm.),or  amylnitrite,  TTLv  (0.3  c.c),  by  inhalation  or  by  mouth. 
For  the  condition  of  status  epilepticus  the  following  combination, 
alternated  with  saline  purgatives,  has  given  good  results: 

I^.     Chloral gr.  xx  1.3  gm. 

Tinct.  cannab.  incidse lUxv  i  .0  c.c. 

Inf.  digitalis f  § j  30. o  c.c. 

M.    S. — Administer  by   enema   every  three  or  four  hours. 

The  use  of  opium  for  a  long  period  has  been  known  to  break  up 
recurrent  maniacal  attacks. 

The  general  condition  of  the  patient  must  receive  careful  attention, 
as  there  is  a  strong  tendency  to  the  development  of  nephritis,  tuber- 
culosis,  and  gastric  catarrh.     These  patients  are  great  feeders — 


KATATONIA  639 

often  gluttons — and  are  sure  to  eat  more  than  they  can  properly  as- 
similate.    Free  action  of  the  bowels  and  kidneys  must  be  promoted. 
Never  contradict,  or  attempt  to  reason  with,  an  epileptic  during 
the  period  of  excitement. 

CIRCULAR  INSANITY 

Synonym. — Folic  circulaire. 

Definition. — A  mental  disease  characterized  by  regularly  alternat- 
ing and  recurring  periods  of  mental  exaltation,  depression,  and 
semilucidity. 

Causes. — Hereditary  predisposition.  The  exciting  causes  are 
any  of  those  conditions  which  depress  the  brain  or  general  system. 

Pathology. — There  is  no  characteristic  lesion  associated  with 
circular  insanity. 

Symptoms. — It  is  essentially  a  chronic  condition  and  probably 
incurable.  The  disease  usually  begins  as  a  melancholia,  the  depres- 
sion being  an  apathy  and  torpor  rather  than  a  mental  pain,  and 
suicidal  feelings  and  impulses  are  rare.  This  condition  is  soon  suc- 
ceeded by  mania,  a  mental  exaltation  with  hyperesthesia  and  exag- 
geration of  nervous  functions,  the  reasoning  power  well  retained; 
this  is  in  turn  followed  by  a  semilucid  interval,  often  giving  promise 
of  recovery,  to  be  sooner  or  later  followed  by  another  cycle.  These 
periods  follow  each  other  with  remarkable  regularity,  each  being 
of  the  same  duration.  Rarely  the  various  periods  are  of  irregular 
duration. 

The  general  health  is  well  maintained,  the  patient  gaining  in 
flesh  during  the  stages  of  depression  and  lucidity  and  losing  during 
the  period  of  exaltation. 

Diagnosis. — The  regularity  of  the  different  periods  soon  establishes 
the  diagnosis. 

Prognosis. — Incurable.  The  affection  ends  in  dementia  after  a 
lapse  of  several  years. 

Treatment. — Attention  to  the  general  health  and  meeting  the  symp- 
toms of  the  different  periods  as  they  recur  constitutes  the  treatment. 
No  means  are  known  to  prevent  the  recurrence  of  the  periods. 

KATATONIA 

Synonyms. — Alternating  insanity;  Kahlbaum's  insanity. 
Definition. — A  mental  disease  characterized  by  irregular  cyclical 
symptoms,  ranging  from  melancholia  to  mania,  followed  by  stupidity 


640  KATATONIA 

and  confusion,  with  cataleptoid  phenomena,  in  turn  followed  by 
lucidity  for  a  time,  recovery,  or  dementia. 

Causes. — Hereditary  predisposition.  The  exciting  causes  are  usu- 
ally the  results  of  some  excess.  Rarely  it  is  associated  with  organic 
brain  disease. 

Pathology. — No  characteristic  lesions  have  been  found  associated 
with  katatonia. 

Symptoms. — A  typical  case  begins  as  a  melancholia,  the  mental 
depression,  uneasiness,  and  distress  followed  after  a  variable  period 
by  mania,  associated  with  hallucinations  and  delusions.  This  period 
is  followed  in  turn  by  a  condition  of  attonita,  or  rigidity  and  im- 
mobility, or  a  cataleptoid  paroxysm.  Any  of  the  stages  may  be 
followed  by  confusional  symptoms,  or  a  true  dementia  may  develop. 
During  the  maniacal  stage  there  is  a  tendency,  in  many  cases,  to 
histrionic  and  sermon-like  declamation,  or  the  speech  may  be  of  the 
verbigeration  character — that  noisy,  incoherent,  and  meaningless 
speech  seen  in  many  manias,  composed  largely  of  the  constant  repeti- 
tion of  a  few  words  or  phrases  without  sense  or  sequence  (onomato- 
mania) . 

During  the  stage  of  attonita  the  presence  of  the  so-called  mutism, 
a  pathological  tendency  to  be  silent,  may  continue  for  days,  weeks, 
or  months,  or  it  may  be  interrupted  by  periods  of  verbigeration. 

The  immobility  or  rigidity  so  characteristic  of  a  period  of  katatonia 
is  frequently  alternated  with  automatic,  incessant,  and  monotonous 
movements — the  stereotyped  movements. 

Patients  suffering  from  katatonia  often  refuse  food  for  days  at 
a  time  and  then  suddenly  present  symptoms  of  boulimia.  Vaso- 
motor and  trophic  changes  are  frequent,  one  of  the  most  constant 
being  cyanosis  of  the  hands  and  other  peripheral  parts.  Hema- 
toma auris,  insane  ear,  or  perichondritis  auriculae,  is  frequent. 
Epileptiform  attacks  may  usher  in  the  disease  or  occur  during  any 
of  its  stages. 

Diagnosis. — It  may  be  diagnosed  as  melancholia,  mania,  or  a 
dementia,  depending  upon  which  part  of  the  cycle  is  first  observed, 
but  after  being  under  observation  long  enough  to  note  a  complete 
cycle  the  diagnosis  is  readily  determined.  Katatonia  differs  from 
circular  insanity  in  the  presence  of  the  stage  of  attonita  and  catalepsy. 

Prognosis. — The  disease  may  continue  for  a  number  of  years  and 
recovery  follow,  but  as  a  rule  the  prognosis  is  unfavorable. 

Treatment. — This  consists  in  attention  to  the  general  condition, 


DELUSIONAL   INSANITY  641 

and  combating  the  various  symptoms  as  they  arise.  In  cases  asso- 
ciated with  anemia,  arsenic  and  strychnine  seem  to  be  valuable. 
When  food  is  refused  by  the  insane,  and  stomach  or  nasal  tube  or 
rectal  feeding  is  necessary,  the  stage  of  food  refusal  is  often  wonder- 
fully shortened  by  adding  sulphonal,  gr.  x  to  xv  (0.6  to  i  gm.),  to 
each  feeding. 

DELUSIONAL  INSANITY 

Synonyms. — Delusional  mania;  delusional  melancholia;  primary 
delusional  insanity. 

Definition. — A  mental  state,  with  fixed  or  partly  systematized 
delusions,  associated  with  either  brain  exaltation  or  excitement 
without  maniacal  acts,  or  a  mental  depression,  minus  the  somatic 
symptoms  of  melancholia. 

An  insane  delusion  is  a  false  belief  for  which  there  is,  or  may  be, 
no  reasonable  foundation  and  which  would  be  incredible  under  the 
given  circumstances  to  the  same  person  if  of  sound  mind,  and  con- 
cerning which  his  mind  is  not  open  to  permanent  correction  through 
evidence  or  argument. 

Causes. — Cerebral  and  bodily  exhaustion,  the  result  of  overwork, 
neglect  of  personal  hygiene,  or  alcohol,  tobacco,  drug  or  sexual  ex- 
cesses, impairment  of  the  nerve-centers  consequent  to  fevers  or  shock, 
the  climacteric  period,  worry,  and  insufficient  food  are  the  most  com- 
mon causes. 

Pathology. — The  affection  runs  a  subacute  or  chronic  course  and 
seldom  ends  directly  in  death,  usually  being  terminated  by  some 
intercurrent  organic  disease.  In  the  few  cases  in  which  post-mortem 
examinations  have  been  made,  the  vessels  of  the  brain  were  found 
torpid  or  dilated,  due  in  all  probability  to  a  vasomotor  paresis  which 
gave  rise  during  life  to  an  imperfect  cerebral  circulation. 

Symptoms. — Either  following  an  attack  of  acute  mania  or  melan- 
cholia, but  more  commonly  without  either  of  these  conditions,  occurs 
a  set  delusion  or  delusions,  which,  to  the  patient,  are  so  real  that  no 
amount  of  argument  can  dispel  his  or  her  belief  in  them.  These 
cases  are  often  classed  as  manias  or  melancholias,  but,  as  they  do  not 
run  the  ordinary  course  of  either  of  these  conditions,  they  are  best 
classed  clinically  by  themselves.  The  acuteness  or  subacuteness 
of  the  attack  distinguishes  them  from  paranoia.  Among  the  almost 
endless  variety  of  delusions  mention  will  be  made  of  a  few  that  have 
come  under  recent  notice:  ''A  young  man  of  twenty  believes  that  he 
41 


642  DELUSIONAL   INSANITY 

is  President;  another  patient,  a  driver,  believed  for  ten  months  that 
he  was  the  owner  of  a  thousand  horses,  any  one  of  which  was  worth 
thousands  of  dollars;  he  made  a  perfect  recovery  and  now  laughs 
at  his  old  delusions.  A  young  man  of  twenty-five  believes  his  m.other 
is  not  his  mother,  but  the  woman  with  whom  he  boarded,  and  that 
his  brothers  and  sisters  are  her  children  but  no  relation  to  him.  A 
young  woman  of  thirty  believes  she  is  pregnant  by  a  prominent 
merchant;  the  fact  being  she  is  not  and  never  has  been  pregnant." 
The  majority  of  the  delusions  are  of  an  egotistic  character,  but  lack  the 
conduct  or  appearance  of  the  position  due  to  the  character  of  the 
delusion.  A  patient  with  ragged  clothing  will  assure  you  that  he  is 
worth  millions,  and  yet  sees  nothing  inconsistent  between  his  delu- 
sions and  his  personal  appearance.  Another  will  assure  you  of  his  vast 
business  interests,  and  yet  remains  contented  in  the  hospital  wards, 
laboring  faithfully  in  the  kitchen  or  laundry.  A  woman  assures  you 
that  she  is  the  great  Patti,  receiving  thousands  of  dollars  for  each 
operatic  performance,  and  yet  is  apparently  happy  in  the  sewing- 
room. 

An  hallucination  is  an  imperfect  perception  through  any  one  of  the 
senses.  A  person  who  imagines  that  he  sees  something,  or  hears 
something,  or  tastes  something,  or  feels  or  smells  something  that  he  is 
not  seeing,  hearing,  tasting,  feeling,  or  smelling,  has  an  hallucination. 

Delusional  insanity  is  often  based  upon  the  development  of  hallu- 
cinations of  the  special  senses,  that  of  hearing  being  the  most  frequent ; 
patients  hear  ''voices"  telling  them  what  to  do  or  not  to  do,  and  a 
delusion  is  built  up  and  developed.  Again,  "voices"  upbraid  them 
or  charge  them  with  various  acts,  and  upon  this  is  developed  a  per- 
secutory delusion  that  causes  them  much  unrest. 

Again,  visions  appear,  which  result  in  delusions  of  personal  impor- 
tance. Taste  and  smell  may  be  perverted,  causing  prolonged  fasting, 
often  from  fear  of  poisoning. 

Diagnosis. — Delusional  mania  and  delusional  melancholia  are  con- 
founded with  delusional  insanity,  the  points  of  distinction  being  the 
absence  of  severe  maniacal  and  melancholic  acts;  the  patient  simply 
possesses  his  insane  delusion  and  may  never  refer  to  it  unless 
questioned. 

Paranoia  or  monomania  and  delusional  insanity  have  many  symp- 
toms in  common,  but  in  the  former  "their  whole  thoughts  and  lives 
show  a  strong  self -consciousness,  and  their  egotism  is  intense" 
(Chapin) ;  and  if  the  patient  believes  he  is  Christ,  he  wishes  to  be  so 


PARANOIA  643 

respected,  and  considers  himself  wronged  if  not  so  treated,  while  the 
delusional  patient  will  say  he  is  Christ  and  immediately  drop  the 
subject.  There  are,  however,  many  borderland  cases  in  which  the 
diagnosis  is  difficult. 

The  distinction  made  here  between  paranoia  and  primary  delu- 
sional insanity  is  not  generally  accepted. 

Prognosis. — In  acute  primary  delusional  insanity,  recovery  is 
frequent,  although  the  delusions  may  exist  for  a  number  of  years. 
Many  patients  who  make  a  complete  recovery  will  still  believe 
that  their  delusions  were  facts.  A  fair  proportion  of  cases  pass  into 
the  condition  of  chronic  delusional  insanity. 

Treatment. — A  supportive  plan  of  treatment,  with  thorough  action 
upon  the  bowels,  kidneys,  and  skin,  and  plenty  of  fresh  air,  is  of  great 
value  in  all  cases  of  delusional  insanity.  If  the  disease  is  the  result 
of  excesses,  a  course  of  strychnine  and  arsenic  is  indicated.  A  tran- 
quil condition  of  the  brain  is  essential,  and  few  combinations  are  so 
valuable  as  digitalis  and  hyoscine,  in  small  repeated  doses.  Insomnia 
is  an  annoying  symptom  in  many  cases,  and  is  best  overcome  by  a 
digestible  meal  at  bedtime,  or  a  warm  or  hot  bath  in  the  evening,  and 
if  these  fail  a  full  dose  of  somnal,  well  diluted,  or  trional,  gr.  xxx 
(2  gm.),  an  hour  before  bedtime,  in  milk  or  spirits  should  be 
administered. 

The  following  is  of  value : 

I^.     Somnal 5iij  12  cic. 

Glycerin 5ss  16  c.c. 

Tr.  cardamom,  comp 5ss  16  c.c. 

Aq.  menth.  pip q.  s.  ad   giij  90  c.c. 

M.  S. — Half  tablespoonful,  repeated  in  two  hours. 

PARANOIA 

Synon3niis. — Monomania;  chronic  delusional  insanity;  reasoning 
mania.  * 

Definition. — A  chronic  mental  disease  characterized  by  fixed  and 
systematized  delusions  of  persecution,  of  unseen  or  impossible 
agencies,  or  of  self-exaltation,  the  emotions  and  memory  being  only 
■paroxysmally  defective,  while  the  life  of  the  individual  is  dominated 
by  the  delusions. 

The  term  paranoia  is  now  commonly  used  to  cover  a  group  of  in- 
sanities which  are  degenerative  in  origin,  chronic  in  course,  and  char- 


644  "GENERAL  PARALYSIS 

acterized  by  systematized  delusions,  with  little  impairment  of  the 
emotional  faculties,  and  is  not  generally  accepted  as  a  synonym  for 
monomania. 

Causes. — There  is  generally  an  hereditary  predisposition  to  insanity 
in  monomania  or  paranoia.  The  exciting  cause  may  be  the  result 
of  an  acute  mania  or  melancholia,  or  the  result  of  alcoholism,  or  of 
malnutrition  in  those  who  have  had  a  struggle  to  keep  their  position 
in  the  world.  Extreme  worry  in  individuals  with  mental  instability 
is  a  common  cause.  It  may  follow  primary  or  acute  delusional  in- 
sanity. 

Symptoms. — The  cause  of  monomania  is  essentially  chronic,  the 
delusions  becoming  fixed  upon  one  particular  subject,  or  set  of  sub- 
jects, which  in  turn  dominate  the  life  of  the  individual.  The  most 
common  characters  of  these  systematized  delusions  are  delusions  of 
persecution  or  suspicion,  delusions  of  exaltation  or  grandeur,  or  of 
pride,  and  delusions  of  unseen  agents  or  influences. 

The  range  which  the  delusions  of  monomania  assume  is  most  wide 
and  varied,  but  always  associated  with  the  ego.  The  patient  is  being 
persecuted  not  because,  as  in  melancholia,  he  has  committed  some 
sin,  or  thinks  he  has,  and  deserves  punishment,  but  because  the  per- 
secutors wish  to  deprive  him  of  his  rights,  titles,  or  estate,  or  degrade 
him,  or  in  some  way  injure  him. 

Diagnosis. — In  the  diagnosis  of  monomania  there  are  three  points 
to.  keep  in  mind:  First,  the  duration — the  fixed,  systematized 
delusions  must  have  existed  over  one  year;  second,  the  absence  of 
symptoms  of  mania  or  melancholia;  and  third,  the  presence  of  sys- 
tematized delusions  affecting  the  personnel  of  the  individual. 

Prognosis. — Monomania  is  an  incurable  disease.  Unless  tubercu- 
losis develops  within  a  few  years,  dementia  results. 

Treatment. — The  various  methods  adopted  for  building  up  and 
maintaining  the  tone  of  the  body  are  applicable  in  this  affection. 
The  symptoms  should  be  combated,  as  they  arise,  on  general  thera- 
peutic principles. 

GENERAL  PARALYSIS 

S5monyms. — General  paresis;  general  paralysis  of  the  insane; 
paresis;  paretic  dementia. 

Definition. — A  subacute  or  chronic,  degenerative  disease  of  the 
brain,  sometimes  involving  the  spinal  cord,  characterized  by  altera- 


GENERAL   PARALYSIS  645 

tions  in  the  intellectual  and  moral  character,  with  the  development 
of  unsystematized  ideas  of  self  importance  or  delusions  of  grandeur, 
finally  merging  into  dementia  (preceded  by  either  a  mania  or  a  melan- 
cholia), and  the  gradual  development  of  tremor,  slurring  speech, 
pupillary  changes,  ataxia,  trophic  changes,  and  finally  general  paresis. 

Causes. — General  paralysis  of  the  insane  occurs  chiefly  between 
thirty  and  fifty-five  years  of  age,  and  in  the  male  more  frequently 
than  in  the  female,  although  a  notable  increase  in  the  lower  class  of 
females  is  being  observed.  It  usually  affects  the  robust,  middle- 
aged  individual,  rapidly  destroying  all  intelligence  and  judgment, 
leaving  him  to  exist,  often  for  months,  as  a  demented  human  automa- 
ton. General  paresis  is  increasing,  and  someone  has  said  that  its  in- 
crease is  in  proportion  to  '^syphilization  and  civilization." 

Predisposing  causes:  Heredity;  an  ambitious  overstraining  for 
prominence,  learning,  or  wealth;  forced  intellectual  activity  in  those 
with  imperfect  or  improper  early  training ;  or  in  those  with  an  imper- 
fectly developed  or  organized  cortex;  cranial  injuries,  and  atheroma. 

Exciting  causes:  Alcoholic  and  sexual  excesses;  syphilis:  mental 
and  physical  overstrain;  and  worry. 

Pathological  Anatomy. — A  condensed  description  of  the  path- 
ological basis  of  general  paralysis  is  difficult.  It  may  be  described 
as  a  chronic,  diffuse,  cortical  encephalitis.  The  microscopical  changes 
in  the  cortex,  according  to  Mendel,  as  quoted  by  Folsom  are  as 
follows : 

1.  Increase  of  nuclei  and  new  cell-formation  are  observed,  some 
nuclei  small,  some  large,  and  with  such  varying  reactions  to  coloring 
agents  as  to  suggest  dissimilarity  of  origin.  The  stellate  or  ''spider" 
cells  are  increased  in  the  upper  layer  of  the  cortex,  where  some  may 
be  normally  found,  and  extend  to  lower  layers,  as  is  not  the  case  in 
normal  brains;  they,  too,  may  be  several  times  the  usual  size  and  also 
push  through  the  white  substance  to  the  ependyma  of  the  ventricles. 
Proliferation  of  neuroglia  or  connective  tissue,  and  in  time  sclerosis 
of  the  cortex  which  involves  the  medullary  substance  also  in  a  greater 
or  less  degree  is  common. 

2.  The  larger  blood-vessels  may  or  may  not  be  atheromatous; 
in  the  capillaries  there  is  an  increase  of  nuclei  in  the  walls,  with  thick- 
ening and  hyaloid  degeneration. 

3.  In  the  nerve-cells,  the  ganglion-cells,  there  are  granular  and  fatty 
degeneration  of  protoplasm,  sclerosis,  and  atrophy. 

4.  Atrophy  and  final  disappearance  of  the  nerve-fibers  is  observed, 


646  "geneeal  paralysis 

not  limited  to  the  cortex.  This  condition  is  found  in  other  brain 
diseases  also — senile  dementia  and  epilepsy,  for  instance. 

5.  Focal  lesions  of  the  most  serious  kinds,  degenerative  changes 
in  the  spinal  cord,  the  several  forms  of  sclerosis,  and  myelitis  are 
encountered. 

The  spinal  cord  undergoes  atrophy  with  gray  degeneration  in 
posterior  and  postero-median  columns,  and  in  the  posterior  spinal 
nerve-roots. 

Symptoms. — For  clinical  convenience  the  disease  is  divided  into 
three  stages — prodromal,  maniacal,  rarely  melancholic,  and  the  stage 
of  dementia — although  there  is  seldom  a  marked  division  between 
the  stages. 

The  prodromal  stage  may  exist  unrecognized  for  months  or  longer. 
It  begins  by  an  alteration  in  the  habits  and  character  of  the  individual, 
such  as  spells  of  irritability  and  obstinacy,  which  will  not  admit  of 
contradiction  or  opposition,  and  there  is  a  general  feeling  of  elation 
and  hien-ttre,  or  egotism,  shown  by  the  exalted  opinion  of  his  own 
attainments  and  importance,  and  a  great  laudation  of  members  of 
his  family.  He  becomes  boastful,  untruthful,  dishonest,  and  forget- 
ful, neglecting  engagements,  business,  self,  and  family.  He  frequently 
makes  extravagant  purchases  and  may  waste  large  sums  of  money 
before  his  condition  of  irresponsibility  is  recognized,  or  may  unwit- 
tingly resort  to  dishonest  means  to  obtain  money.  In  many  instances 
the  patient  develops  ideas  of  an  enterprising  character,  and  resorts 
to  all  forms  of  expedients,  which,  to  his  mind,  are  going  to  improve 
his  or  his  family's  station  and  worldly  condition.  He  determines  to 
change  his  occupation  or  business  or  attempts  to  instruct  the  authori- 
ties in  what  he  conceives  should  be  their  duties. 

Moral  lapses  or  paretics  are  most  frequent  during  this  stage,  con- 
sisting of  acts  of  theft,  drunkenness,  violent  impulses,  or  indecent 
assaults,  in  individuals  who  have  previously  possessed  a  good  moral 
character.  They  become  profane  and  vulgar,  and  often  resort  to 
sexual  excesses.  Associated  with  any  of  the  above  symptoms  may 
be  any  one  or  more  of  the  following  physical  conditions :  Tremor  of 
the  muscles  about  the  mouth,  nasolabial  folds,  and  of  the  tongue,  caus- 
ing a  slight  slur  or  hesitating  speech;  alterations  in  the  pupils,  or  one 
pupil  becoming  somewhat  larger  than  the  other,  or  the  pupils  may  be 
contracted  to  pin-head  size  with  loss  of  accommodation ;  attacks  of  ver- 
tigo, or  epileptiform  or  apoplectiform  seizures.  The  gastric,  intes- 
tinal, hepatic,  and  nephritic  secretions  are  disturbed,  and  there  may 


GENERAL   PARALYSIS  647 

be  headache  and  insomnia.  After  a  variable  duration,  continuing 
in  a  mild  degree  for  many  months,  the  second  stage  begins. 

Second  or  maniacal  stage  is  much  the  same  as  a  severe  attack  of 
acute  mania  (megalomania),  plus  the  physical  signs  of  paresis  and 
the  delusions  or  ideas  of  grandeur.  The  patient  is  excessively  rest- 
less, boasting  of  his  great  wealth,  intentions,  prospects,  and  influence ; 
one  moment  the  most  important  of  individuals,  the  next  giving  away 
thousands,  and,  if  doubt  is  expressed  as  to  his  ability  to  do  so,  making 
it  millions  and  often  billions;  presenting  houses  and  lands,  titles 
and  offices,  with  unstinted  liberality.  It  is  to  be  noted  that  these  so- 
called  delusions  of  the  paretic  are  in  reality  conceptions,  or  an  ex- 
pansive delirium,  for  when  contradicted  the  patient  makes  no  effort 
to  defend  them;  they  seem  to  be  really  assertions  and  reassertions, 
continuing  until  incoherency  restrains  the  airy  imagination.  If 
questioned  as  to  his  health,  he  replies,  enthusiastically,  'Tirst-rate; 
never  better  in  my  life."  The  patient  is  sleepless,  noisy,  and  destruc- 
tive, with  attacks  of  blind,  uncalculating  violence,  resisting  all  who 
attempt  to  restrain  or  molest  him.  The  violent  impulses  of  paretics 
are  similar  to  the  furious  excitement  of  the  post-epileptic  maniac. 

The  physical  signs  are  more  pronounced:  the  characteristic,  hesita- 
ting and  slurring  speech  increases;  the  pupillary  changes  becoming 
more  marked;  the  tremor  of  the  tongue  and  lips  increasing  and  spread- 
ing to  the  upper  extremities;  the  gait  ataxic;  the  patellar  reflex  in- 
creased, or,  rarely,  diminished;  the  sphincter  of  the  bladder  dis- 
ordered, and  sometimes  there  occurs  paralysis  of  the  anal  sphincter. 

During  the  progress  of  the  second  stage  are  developed  cerebral 
crises — syncope,  petit  or  grand  mal,  apoplectiform  attacks,  or  par- 
alytic seizures.  Few  cases  but  show  one  or  more  of  these  conditions. 
There  also  occur  miosis  and  loss  of  light  reaction,  and  increased  wrist 
and  elbow  jerks.  The  maniacal  stage  is  of  shorter  duration  than  any 
other,  and  is  usually  succeeded  by  the — 

Stage  of  dementia,  the  patient  presenting  all  the  evidences  of  failing 
mentality,  with  paralysis,  trophic  changes,  as  shown  by  the  occur- 
rence of  bed-sores,  cystitis,  diarrhea,  and  arthropathies,  or  Charcot's 
joints,  the  patient  emaciating  rapidly,  death  closing  the  scene  within 
a  few  months.  Rarely,  the  maniacal  stage  is  preceded  or  replaced  by 
a  condition  of  melancholia  with  expansive  hypochondriacal  delusions. 
In  a  few  instances  a  genuine  lucid  interval  has  followed  either  the 
prodromal  or  maniacal  stage. 

The  spinal  form  of  general  paresis  if  fairly  frequent,  in  which  symp- 


648  DEMENTIA 

toms  of  spinal  sclerosis  are  added  to  the  mental  ataxic  phenomena 
of  the  usual  form. 

Diagnosis. — The  development  of  the  following  symptoms  re- 
moves all  difficulties  in  diagnosis:  Mental — alteration  in  character, 
loss  of  memory,  defective  will-power,  changed  moral  sense,  insomnia, 
violent  impulses,  melancholia  or  mania,  unsystematized  delusions 
of  expansive  character,  with  an  exalted  sense  of  well-being,  gradually 
ending  in  dementia.  Physical — hesitating,  slurring  speech;  tremor 
of  the  lips,  tongue,  and  upper  extremities,  pupillary  changes,  miosis, 
loss  of  light  reaction;  exaggerated  wrist-,  elbow-,  and  knee-jerk; 
attacks  of  syncope,  vertigo,  epileptiform  seizures,  ataxia,  trophic 
changes,  and  finally  paralysis. 

Paralytic  insanity,  organic  dementia,  or  dementia  paralytica,  is 
not  the  same  condition  as  general  paralysis.  It  is  the  form  of  mental 
failure  succeeding  to  gross  brain  lesions,  such  as  apoplexy,  tumors, 
softening,  trauma,  and  sclerosis,  associated  with  either  hemiplegia  or 
paraplegia. 

Prognosis. — Unfavorable.     Remissions   very   rarely   occur.     The 
duration  of  general  paresis  has  been  considerably  lengthened  by  the 
hospital  care  of  such  patients  now  in  vogue  in  all  properly  conducted 
.  institutions  for  the  insane. 

Treatment. — The  care  of  the  general  health  and  meeting  symptoms 
as  they  arise  are  all  that  can  be  done  for  general  paresis.  It  is  claimed 
that  if  the  condition  be  recognized  early  in  the  prodromal  stage,  the 
stage  of  cerebral  congestion  or  vasomotor  paresis,  much  good  may  be 
accomplished,  and,  if  not  cured,  may  be  held  in  check  for  a  long 
period  of  time  by  the  use  of  such  drugs  as  digitalis  or  ergot. 

The  maniacal  excitement  maybe  quieted  by  the  use  of  the  hot  bath, 
isolation  (not  seclusion),  and  the  administration  of  small  doses  of 
hyoscine  hydrobromide,  which  seems  to  exert  an  alterative  action  on 
the  brain.  For  the  insomnia,  trional,  gr.  xx  to  xxx  (1.3  to  2  gm.), 
repeated,  is  usually  satisfactory. 

If  a  reliable  syphilitic  history  is  obtained,  a  thorough  course  of  mer- 
cury and  iodides  should  be  administered.  All  means  that  promote 
the  constructive  metamorphosis  are  indicated  in  this  most  character- 
istic, progressive  malady. 

DEMENTIA 

Synonym. — Acquired  feeble-mindedness. 

Definition. — A  progressive  general  weakening  of  the  mind,  charac- 


DEMENTIA  049 

terized  by  a  loss  of  reasoning  capacity,  a  diminution  of  feeling,  a  weak- 
ened volitional  and  inhibitory  power,  and  failure  of  memory,  associ- 
ated with  lack  of  the  power  of  attention,  interest,  and  curiosity,  in 
varying  degrees,  in  an  individual  previously  possessed  of  these  mental 
qualities. 

Forms. — Acute  dementia;  alcoholic  dementia;  dementia  apoplectica 
or  paralytica;  dementia  choreica;  chronic  or  secondary  dementia;  de- 
mentia epileptica;  organic  dementia;  partial  dementia;  primary  dementia; 
dementia  senilis;  dementia  syphilitica;  dementia  toxica. 

Causes. — Deficient  or  feeble  mental  inheritance;  age;  atheroma; 
mania,  melancholia,  paranoia,  and  other  forms  of  insanity;  organic 
brain  conditions;  alcoholism;  syphilis;  developmental  changes; 
climacteric. 

Pathology. — In  acute  dementia  the  changes  are  dynamic.  In 
primary  dementia  there  is  probably  atrophy  of  certain  cells  from  over- 
stimulation, the  tissues  being  normally  deficient.  In  secondary  de- 
mentia the  chief  changes  are:  ''alteration  in  the  size  of  the  vessels, 
owing  to  the  thickening  and  distention,  the  thickening  being  most 
marked  in  the  deep  layers,  and  in  the  walls  of  the  vessels  are  fatty 
granules  and  hematoidin.  The  perivascular  canals  are  enlarged. 
The  changes  in  the  cells  may  be  described  as  deficiency  in  the  number 
of  pyramidal  cells,  and  a  want  of  distinctness  of  outline  and  branches, 
the  nuclei  being  larger,  but  changed  in  form,  and  only  capable  of 
slight  carmine  staining."  In  senile  dementia  there  is  general  atrophy 
and  degeneration  of  all  the  tissues  of  the  brain. 

Symptoms. — The  onset,  extent,  and  variety  of  the  impaired  men- 
tality differ  greatly.  In  some  patients  the  evidences  of  the  failing 
mind  are  seen  with  the  subsidence  of  the  mania,  melancholia,  or 
other  insanity,  or  soon  after  the  development  of  the  particular  cause, 
while  in  another  group  of  cases  the  development  is  slow  and  insidious. 
The  difference  in  the  intensity  is  marked;  in  one  cases  the  changes 
being  scarcely  noticeable,  the  patient  being  simply  less  active  than 
before,  showing  a  slight  indifference  to  his  environment;  while  in 
others  the  patients  remain  for  hours  alone,  making  no  effort  at  move- 
ment and  with  little  or  no  expression  of  the  face;  while  still  another 
class  of  cases  is  oblivious  to  the  demands  for  food  or  drink,  or  the 
calls  of  nature,  existing  "in  the  darkness  of  perpetual  intellecttial  and 
moral  night."  Between  these  extremes  are  all  varieties  and  de- 
grees of  mental  enfeeblement,  the  physical  symptoms  of  dementia 
varying _with  the  particular  cases,  many  enjoying  the  best  of  health. 


650  .    DEMENTIA 

eating  and  sleeping  well;  while  others  are  always  unwell,  first  one 
organ  and  then  another  being  affected;  still  another  group  suffer 
from  chronic  diarrhea,  which  finally  causes  death.  Dementia  patients 
seem  predisposed  to  tuberculosis,  nephritis,  and  epilepsy. 

Acute  dementia,  or  "stupor  with  dementia,"  is  to  be  distinguished 
from  "stupor  with  melancholia."  The  onset  is  rather  sudden,  with 
or  without  mania  or  melancholia,  after  some  brain  or  bodily  exhaus- 
tion, shock,  or  fright;  the  patient,  a  young  person,  "is  horror-stricken, 
paralyzed  in  mind,  not  merely  deranged,  not  depressed  or  excited, 
but  deprived  of  feeling  and  intellect,  his  movements,  if  there  be  any, 
are  automatic,  but  frequently  he  is  motionless,  standing  or  sitting, 
staring  at  vacancy  for  hours  and  days"  (Blandford).  These  patients 
will  not  converse,  and  do  not  reply  to  questions,  or  but  slowly,  and  in 
monosyllables,  and  their  faces  have  a  blank  expression. 

Alcoholic  dementia,  the  mental  weakness  resulting  from  excessive 
use  of  alcohol.  Inebriety  is  a  form  of  dementia,  there  existing  an 
uncontrollable  alcoholic  habit,  with  weakened  or  absent  will-power 
and  impaired  mentality.  Sutherland  defines  seven  forms  of  insanity 
from  alcoholic  excess:  (i)  Intoxication;  (2)  delirium  tremens; 
(3)  mania-a-potu ;  (4)  dipsomania;  (5)  mania  of  suspicion;  (6)  chronic 
alcoholism  or  dementia;  (7)  general  paralysis. 

Dementia  apoplectica  or  paralytica  is  an  organic  or  terminal  dementia 
due  to  the  cerebral  changes  sometimes  following  a  severe  apoplectic 
seizure,  and  is  usually  associated  with  hemiplegia. 

Dementia  choreica  is  a  feeble-mindedness  associated  with  chronic 
or  hereditary  chorea,  or,  in  some  cases,  probably  the  result  of  chorea. 

Chronic  dementia  is  the  designation  applied  to  all  forms  of  dementia 
that  have  existed  for  one  or  more  years. 

Dementia  epileptica  is  the  slow  mental  impairment  resulting  from 
long-continued  and  frequently  occurring  epileptic  convulsions. 

Organic  dementia,  the  mental  deterioration  resulting  from  gross 
organic  brain  lesions,  such  as  sclerosis,  tumor,  embolism,  or  trauma. 

Partial  dementia  is  an  incomplete  form  of  dementia  in  which 
the  mental  enfeeblement  is  associated  with  such  a  degree  of  intelli- 
gence and  memory  that  the  qualifying  term  "partial"  is  applicable. 
This  variety  of  dementia  constitutes  the  majority  of  able-bodied, 
working,  chronic  insane  patients  seen  in  insane  hospitals. 

Primary  dementia  is  seen  most  frequently  in  the  young,  devel- 
oping slowly  and  insidiously,  without  any  symptoms  of  mania  or 
melancholia,  usually  in  a  youth  who  has  given  promise  of  a  bright 


'  DEMENTIA  65 1 

future,  by  a  slowly  progressive  indifference  to  his  former  occupation, 
studies,  or  surroundings,  with  developing  carelessness  and  negligence 
of  person  and  proprieties,  no  amount  of  external  stimulus  serving  to 
rouse  the  receding  mentality,  until  finally  the  downward  course  ends 
in  dementia  so  decided  that,  but  for  the  history  of  the  individual, 
the  case  would  be  classed  as  congenital,  or  imbecility. 

Secondary,  sequential  or  chronic  dementia,  is  the  most  common 
variety  of  mental  impairment  following  mania,  melancholia,  and 
other  insanities.  According  to  Bevan  Lewis,  20  per  cent,  of  manias 
and    15   per   cent,   of   melancholias   become  permanent   dementia. 

Dementia  senilis  is  the  result  of  cerebral  atrophy,  with  its  con- 
sequent failing  mental  power.  Loss  of  memory  for. recent  events 
is  one  the  most  common  symptoms.  The  disease  often  begins  as  a 
senile  mania,  melancholia,  or  delusional  insanity. 

Dementia  syphilitica  is  the  feeble-mindedness  resulting  from  cere- 
bral  syphilis.  These  patients  are  always  sanguine,  and  assert  they 
are  "all  right,"  "never  sick  in  my  life,"  and  yet  are  unable  to  assist 
or  care  for  themselves.  This  form  of  dementia  has  many  symptoms 
akin  to  general  paresis,  and,  indeed,  is  often  termed  "pseudo-paresis." 

Dementia  toxica  is  the  mental  failure  produced  by  the  long- 
continued  and  excessive  use  of  opium,  cocaine,  and  chloral.  Chronic 
plumbism  is  also  given  as  a  cause. 

Diagnosis. — Acute  dementia  is  often  misnamed  melancholia  with 
stupor,  but  if  the  patient  is  in  the  teens  the  probabilities  are  that  it 
is  a  case  of  the  former,  while  if  past  forty  it  is  almost  certainly  the 
latter. 

The  distinction  between  dementia  and  idiocy  or  imbecility  must 
always  be  determined.  Esquirol's  graphic  description  is  well  worth 
remembering:  "The  dement  was  a  rich  man  who  has  become  poor; 
the  idiot,  on  thecontrary,  has  always  been  in  a  state  of  want  and 
misery." 

Prognosis. — Acute  dementia  is  generally  favorable.  All  other 
varieties  are  incurable.  The  average  life-time  of  dements  is  placed 
at  about  twelve  years,  the  great  majority  dying  of  tuberculosis, 
nephritis,  or  apoplexy. 

Treatment. — Patients  suffering  from  acute  dementia  should  be 
placed  on  the  Mitchell  rest  regime,  with  attention  to  all  the  secre- 
tions. If  Dr.  Mitchell's  directions  are  carefully  followed  the  great 
majority  of  cases  of  acute  dementia  will  recover  within  nine  to  twelve 
months. 


652 


DISEASES    OF    THE    SKIN 


For  the  other  forms  of  dementia,  unfortunately,  there  is  no  cure, 
the  treatment  resolving  itself  into  attention  to  the  general  health, 
with  proper  custodial  oversight. 

DISEASES  OF  THE  SKIN 

General  Sjmiptomatology. — To  acquire  even  the  most  slight  knowl- 
edge of  diseases  of  the  skin,  a  definite  understanding  of  the  indi- 
vidual lesions  or  objective  phenomena  must  be  obtained,  as  it  is  the 
aggregation  of  these  lesions  that  constitutes  the  external  manifesta- 
tions of  these  affections  and  the  basis  of  diagnosis.     Some  lesions 

Macule  — ^ . 


Papule 


Tubercle 


Vesicle 


A 


Crust 


Pustule 


Scale 


Tumor 


~  Excoria- 
tion 


V 


V 


—    XXX 

Secondary 


Fissure 


Ulcer 


Cicatrix 


Primary 

Fig.  6o. — Lesions   of  the  Skin.     {After  Gould  and  Pyh's  "Cyclopedia  of  Medicine  and 

Surgery".) 

are  initial  manifestations  and  are  termed  primary  lesions;  others  re- 
sult from  various  modifications  of  the  original  lesions  and  are  termed 
secondary  lesions. 

The  primary  lesions  are  macules,  papules,  vesicles,  blebs,  pus- 
tules, tubercles,  wheals,  and  tumors.  These  represent  definite 
structural  changes  in  the  skin.  The  definitions  of  these  terms  by- 
various  dermatologists  must  therefore  be  very  similar. 

Macules  are  variously  sized  and  shaped  discolored  areas  of  the  skin 
characterized  by  the  absence  of  elevation  or  depression. 


HYPEREMIA    OF   THE    SKIN  653 

Papules  are  circumscribed  solid  areas  of  elevations  of  the  skin,  the 
size  of  which  varies  from  that  of  a  pin-head  to  a  pea. 

Vesicles  are  circumscribed  elevated  areas  of  the  skin  containing 
clear  or  opaque  fluid,  varying  in  size  from  a  pin-head  to  a  pea. 

Blehs  or  hullce  are  round  or  irregularly  shaped  epidermal  elevations 
containing  clear  or  opaque  fluid  and  varying  in  size  from  a  pea  to  a 
goose-egg. 

Pustules  are  circumscribed  epidermal  elevations  containing  pus, 
and  varying  in  size  from  a  pin-head  to  a  finger-nail. 

Wheals  or  pomphi  are  circumscribed  edematous  elevations  of  the 
skin  of  a  fugitive  or  ephemeral  character. 

Tubercles  are  circumscribed,  solid,  pea-sized  elevations,  situated 
deeply  in  the  skin. 

Tumors  are  variously  sized,  shaped,  and  constituted  prominences 
the  seat  of  which  is  in  the  deep  layers  of  the  integument. 

The  secondary  lesions  include  scales,  crusts,  excoriations,  fissures, 
ulcers,  scars,  stains,  and  any  other  secondary  structural  change. 
These  manifestations  do  not  bear  directly  on  the  diagnosis  and  their 
detailed  description  may  therefore  be  omitted. 

Subjective  symptoms  in  dermatological  affections  are  itching,  burning, 
tingling,  smarting,  pain,  and  sense  of  heat.  The  intensity  of  these 
manifestations  is  necessarily  subject  to  great  variation.  They  may 
exist  separately  or  in  different  degrees  of  combination. 

ANEMIA  OF  THE  SKIN 

Anemia  of  the  skin  consists  in  a  diminution  in  the  quantity  or 
alteration  in  quality  of  its  blood  supply  and  may  be  general  or  local, 
transient  or  persistent.  Generalized  dermal  anemia  occurs  as  a  part 
of  a  general  anemia  from  various  causes,  and  as  a  result  of  cerebral 
anemia.  Localized  anemia  follows  the  application  of  cold,  pernio, 
frost-bite,  Raynaud's  disease,  emboli  and  thrombi,  keloid,  morphea, 
scleroderma,  alopecia  areata,  cicatrices,  etc.  Transient  anemia  oc- 
curs as  the  result  of  shock,  syncope,  anger,  fear,  hemorrhages,  etc. 
Persistent  anemia  is  that  which  occurs  as  the  result  of  some  structural 
change  in  the  skin  such  as  morphea  and  alopecia  areata;  it  also  ac- 
companies persistent  general  anemias. 

HYPEREMIA  OF  THE  SKIN 

Hyperemia  or  congestion  of  the  skin  consists  in  an  increase  of  its 
blood  supply  due  to  overfilling  of  the  blood-vessels  without  other 


654  ERYTHEMA  MULTIFORME 

Structural  change.  As  in  other  parts  of  the  body,  it  may  be  active 
or  passive,  idiopathic  or  symptomatic.  The  most  important  hyper- 
emias are  erythema  simplex  and  erythema  intertrigo. 

Erythema  simplex  is  a  circulatory  disturbance  of  the  integument 
characterized  by  variously  sized  and  shaped  areas  of  redness  unat- 
tended by  elevation  or  depression.  It  is  accompanied  by  mild  itching 
or  burning,  and  disappears  on  pressure.  It  may  be  due  to  exposure  to 
extremes  of  temperature  {erythema  caloricum),  exposure  to  the  sun's 
rays  {erythema  solar e),  injury  {erythema  traumaticum),  irritation  of 
poisonous  plants  {erythema  venenatum),  or  to  the  absorption  of  drugs, 
antitoxins,  ptomaines,  etc.  {toxic  erythema). 

The  treatment  should  be  internal  and  external.  As  many  of  these 
cases  are  due  to  intestinal  autointoxication,  fractional  doses  of  calo- 
mel followed  by  a  saline  purgative  should  be  administered  routinely, 
except  in  those  instances  in  which  the  affection  is  obviously  due  to 
external  causes.  Externally,  dusting  powders  such  as  zinc  oxide  and 
starch,  and  sedative  lotions  such  as  saturated  boric-acid  solution  are 
very  beneficial. 

Erythema  intertrigo  or  chafing  is  the  variety  of  hyperemia  encoun- 
tered in  regions  such  as  the  buttocks,  genital  regions,  and  flexures  of 
joints,  in  which  the  skin  surfaces  are  in  apposition  and  rub  one  on 
the  other.  In  the  obese  and  in  infants  it  is  very  frequent  and  often 
develops  into  a  true  dermal  inflammation. 

Redness,  heat,  and  burning  are  symptoms,  and  sometimes  there 
may  be  a  mucoid  discharge.  Cleanliness  and  the  local  application  of 
dusting  powders  such  as  magnesium  carbonate,  zinc  oxide,  subnitrate 
of  bismuth,  talc,  etc.,  serve  to  prevent  and  relieve  the  condition. 

INFLAMMATIONS  OF  THE  SKIN 

ERYTHEMA  MULTIFORME 

Erythema  multiforme  is  an  inflammatory  disease  of  the  skin  char- 
acterized by  symmetrical,  bright  or  dark  reddish,  more  or  less  varie- 
gated macules,  papules,  and  vesicles,  occurring  discretely  or  in  patches, 
often  sharply  defined,  and  marginate,  of  various  sizes  and  shapes,  run- 
ning an  acute  course  (Duhring).  Constitutional  disturbance  usually 
precedes  or  accompanies  it,  and,  is  manifested  by  feverishness,  mal- 
aise, rheimiatoid  pains,  anorexia,  etc.  This  is  followed  by  the 
sudden  appearance  of  the  eruption  which  may  consist  of  macules, 


ERYTHEMA   SCARLATINOIDES  655 

papules,  vesicles,  or  blebs,  the  eruption  being  designated  by  the  pre- 
dominant type  of  lesions.  It  is  bright  or  dusky  red  in  color  at  first, 
but  soon  becomes  purplish  or  bluish  and  shows  a  great  predilection 
for  extensor  surfaces,  such  as  the  backs  of  hands  and  dorsal  surfaces  of 
the  feet.  Other  portions  of  the  body,  however,  are  not  exempt. 
The  subjective  symptoms  are  itching  and  burning. 

The  direct  cause  of  the  affection  is  undetermined,  but  early  adult 
life,  spring  and  autumn  seasons,  changes  in  the  weather,  and  the 
rheumatic  diathesis  are  known  to  influence  its  production  materially. 
The  pathological  changes  consist  in  dilatation  of  the  dermal  vessels 
with  moderate,  serous  and  cellular  exudation  into  the  tissues.  In 
distinguishing  the  condition  from  other  cutaneous  affections  it  should 
be  remembered  that  the  eruption  appears  suddenly  in  crops  lasting 
from  one  to  four  weeks,  is  multiform  in  character,  is  most  marked 
on  extensor  surfaces,  has  a  purplish  red  or  violaceous  color,  is  ac- 
companied by  constitutional  symptoms,  and  undergoes  spontaneous 
involution  often  reappearing  when  the  necessary  contributory  condi- 
tions (such  as  change  in  the  weather)  are  supplied. 

Treatment. — In  all  cases,  the  administration  of  fractional  doses 
of  calomel  followed  by  a  saline  is  of  benefit.  Quinine  and  the  sali- 
cylates often  serve  to  hasten  the  eruption's  involution  and  to  relieve 
the  constitutional  manifestations.  Locally,  antipruritic  lotions  are 
of  value.     The  following  may  be  used: 

I^.     Acid  carbol 5ij  8  c.c. 

Glycerin 5ij  8  c.c. 

Aquae Oj  480  c.c. 

M.  S. — Poison,  apply  locally  twice  daily. 

ERYTHEMA  SCARLATINOIDES 

Erythema  scarlatinoides  is  a  variety  of  exudative  erythema 
resembling  scarlet  fever  in  its  cutaneous  manifestations  but  differing 
from  it  in  its  other  characteristics.  The  eruption  appears  suddenly 
with  very  slight  constitutional  reaction,  is  punctiform  or  diffuse, 
and  disappears  by  desquamation  in  from  one  to  six  days.  The  face 
is  seldom  attacked;  the  strawberry  tongue  is  absent;  recurrence  is 
common;  and  the  affection  is  non-contagious.  It  may  arise  as  an 
idiopathic  condition  or  it  may  accompany  septicemia,  pyemia, 
ptomaine  poisoning,  rheumatism,  uremia,  and  the  infectious  fevers. 
A  similar  eruption  may  follow  the  absorption  of  quinine,  salicylates, 


656  ERYTHEMA   NODOSUM 

copaiba,  belladonna,   and  similar  drugs.     The  affection  is  devoid 
of  danger  and  terminates  favorably  usually  within  a  week. 

Treatment. — When  the  cause  can  be  ascertained,  it  should  be 
promptly  removed  in  order  to  prevent  persistence  or  recurrence  of 
the  condition.  Usually  no  local  treatment  is  required.  Dusting 
powders  or  sedative  lotions  may  be  necessary  if  there  is  any  attendant 
itching. 

ERYTHEMA  NODOSUM 

Erythema  nodosum  is  an  inflammatory  disease  attended  by  the 
formation  of  symmetrical,  round  or  oval,  node-like  swellings  and  ac- 
companied by  more  or  less  constitutional  disturbance.  The  onset 
is  marked  by  slight  fever,  rheumatoid  pains,  and  loss  of  appetite. 
These  are  shortly  followed  by  the  appearance  of  tense,  rosy,  red  nodes 
or  swellings,  usually  over  both  tibiae,  resembling  erysipelas.  They 
are  at  first  hard  and  extremely  tender  to  the  touch  but  later  soften 
and  their  color  becomes  that  of  a  bruise.  Suppuration  never  occurs 
and  the  lesions  undergo  spontaneous  involution  in  from  a  week  to 
ten  days.  The  affection  is  usually  observed  in  children  and  young 
adults  particularly  in  the  spring  and  fall.  It  is  often  associated  with 
rheumatism  and  gastrointestinal  disorders.  The  structural  changes 
incident  to  this  disease  are  congestion,  serous  and  cellular  infiltration, 
and  hemorrhages.     It  is  closely  related  to  erythema  multiforme. 

Treatment. — Rest,  with  elevation  of  the  affected  parts  is  essen- 
tial. The  application  of  lead-water  and  laudanum  serves  to  relieve 
the  pain.  On  no  account  should  the  lesion  be  incised.  Internally, 
fractional  doses  of  calomel  followed  by  a  saline  should  be  given  to 
relieve  the  gastrointestinal  tract  of  any  offending  material  and  to 
promote  elimination.  Quinine,  salol,  salicin,  sodium  salicylate, 
and  phenacetin  may  be  employed  with  benefit. 

ERYTHEMA  INDURATUM 

Erythema  induratum  is  an  uncommon  inflammatory  affection 
observed  in  scrofulous  individuals,  particularly  strumous  girls,  char- 
acterized by  the  formation  of  circumscribed  infiltrated  areas,  usually 
in  the  calves  of  the  legs,  which  terminate  either  in  absorption  or  ne- 
crosis with  the  formation  of  an  indolent  ulcer.  Overwork  and  pro- 
longed standing  seem  to  be  etiological  factors.  It  occurs  usually 
in  winter  in  poorly  nourished  individuals  with  feeble  circulation, 
and  is  extremely  chronic  with  a  tendency  to  recurrence. 


URTICAEIA  657 

Treatment. — In  all  cases  it  is  extremely  necessary  first  to  improve 
the  patient's  general  condition  by  good  food,  fresh  air,  sunshine, 
cod-liver  oil,  syrup  of  the  iodide  of  iron,  and  similar  measures.  Lo- 
cally, elevation  of  the  parts  is  of  decided  advantage  and  in  event  of 
ulceration,  surgical  cleanliness  is  all  that  is  necessary. 

URTICARIA 

Synonyms. — Hives;  nettle-rash. 

Definition. — An  inflammation  of  the  skin  characterized  by  the 
development  of  wheals  of  a  whitish,  pinkish,  or  reddish  color,  ac- 
companied by  stinging,  pricking,  and  tingling  sensations,  often 
associated  with  febrile  and  gastric  symptoms. 

Causes. — It  is  usually  due  to  some  indiscretion  in  diet.  Certain 
substances  such  as  fish,  crabs,  lobsters,  cheese,  sausage,  buckwheat, 
strawberries,  nuts,  pork,  etc.,  in  susceptible  individuals  bring  about 
an  attack.  Antitoxin  serums,  copaiba,  quinine,  cubebs,  chloral, 
salicylic  acid,  morphine,  etc.,  may  also  give  rise  to  the  condition. 
Intestinal  parasites  and  undigested  food  are  also  causes.  Locally, 
the  bites  or  stings  of  insects,  exposure  to  heat,  the  sting  of  the  nettle, 
and  traumatism  such  as  caused  by  the  stroke  of  a  whip -lash,  often 
produce  the  condition.  Less  frequent  causes  include  reflex  irritation 
from  hepatic,  renal,  uterine,  or  bladder  derangements,  puncture  of 
pleural  effusion,  rupture  of  an  hydatid  cyst,  malaria,  emotion,  neurotic 
conditions,  purpura,  pregnancy,  lactation,  and  the  menopause. 

Pathology. — An  acute  edematous  condition  of  the  papillary  layer 
of  the  skin,  characterized  by  the  rapid  development  of  a  ''wheal" — 
a  more  or  less  firm  elevation — consisting  of  a  circumscribed  collection 
of  the  semifluid  material,  the  result  of  a  rapid  exudation  into  the 
upper  layers  of  the  skin.  The  production  of  the  wheal  is  the  immedi- 
ate result  of  the  disturbance  of  the  vasomotor  system,  which  is  shown 
by  the  interference  of  the  circulation  in  the  wheal,  the  blood  being 
driven  from  its  center  to  its  periphery,  causing  the  whitish  apex  and 
red  areola  so  characteristic  of  the  developed  ''hive." 

Symptoms. — An  attack  of  "hives"  is  characterized  by  the  sudden 
development  of  wheals  upon  the  cutaneous  surface,  which  usually  as 
suddenly  disappear,  their  site  being  temporarily  marked  by  a  spot  of 
redness  or  hyperemia.  With  the  appearance  of  the  wheal  occur  dis- 
tressing itching,  burning,  tingling,  crawling,  pricking,  and  stinging 
sensations,  to  relieve  which  the  patient  still  further  irritates,  tears,  or 
42 


658  •  URTICARIA 

otherwise  wounds  the  surface  by  scratching,  whence  are  often  devel- 
oped deep-colored,  fiat,  lenticular  papules. 

Very  frequently  an  attack  of  "hives"  is  associated  with  fever, 
headache,  and  gastric  disorder.  The  wheals  may  appear  upon  any 
portion  of  the  body;  their  size  varies  from  that  of  a  pea  to  that  of  a 
walnut  or  an  egg — "giant  wheals;"  the  number  varying,  sometimes 
being  so  numerous  as  to  cover  the  whole  surface.  The  shape,  size, 
color,  and  number  of  the  wheals  that  may  occur  have  given  rise  to  a 
■  number  of  names  to  designate  the  lesions.  Thus,  urticaria  annularis 
occurs  in  rings;  urticaria  figurata  occurs  in  spirals;  urticaria  vesiculosa 
has  a  vesicular  development  on  the  summit  of  the  wheal;  urticaria 
bullosa,  a  bullous  development  at  the  summit;  urticaria  papulosa,  or 
lichen  urticatus,  the  wheal  and  a  small  papule  are  combined;  urticaria 
tuber  OS  a,  or  giant  wheals;  urticaria  hcemorrhagica,  or  urticaria  pur- 
pur  ata,  a  combination  of  urticaria  and  purpura;  urticaria  evanida,  a 
rapid  appearance  and  disappearance  of  the  lesion;  urticaria  perstans, 
slow  disappearance;  urticaria  conferta,  when  the  wheals  are  confluent; 
urticaria  pigmentosa,  when  the  wheals  are  succeeded  by  pigmenta- 
tions of  the  site,  the  tints  varying  from  buff -brown,  greenish  yellow, 
to  a  chocolate  color;  urticaria  febr His,  when  the  wheals  are  associated 
with  fever;  urticaria  ab  ingestis,  when  associated  with  indigestion, 
urticaria  factitia,  when  the  wheals  are  produced  artificially. 

Prognosis. — Acute  attacks  respond  quickly  to  treatment,  but  re- 
currences are  common. 

Treatment. — In  the  early  stage,  an  emetic  will  be  of  value  but 
usually  the  condition  is  well  advanced  when  seen  by  the  physician, 
necessitating  the  administration  of  a  brisk  purgative.  Following 
this  some  intestinal  antiseptic  such  as  salol,  or  sodium  salicylate 
should  be  given.  The  diet  should  be  as  plain  as  possible,  care  being 
taken  to  eliminate  those  substances  for  which  the  patient  has  an 
idiosyncrasy.  Among  other  drugs  of  value  in  this  condition  may  be 
mentioned  quinine,  phenacetin,  antipyrine,  pilocarpine,  atropine, 
tincture  of  belladonna,  ammonium  chloride,  arsenic,  and  potassium 
bromide.     The  following  pill  is  useful  in  many  cases : 

I^.  Pulv.  pilocarpi, 

Ext.  guaiaci aa  gr.  I'ss  aa  o.  i  gm. 

Lithii  benzoat gr.  iij  0.2  gm. 

M.  S. — Two  to  four  each  twenty-four  hours. 

If  there  be  atonic  dyspepsia  and  constipation,  the  following  combi- 
nation is  beneficial: 


UETICARIA  659 

I^.     Magnesii  sulphat 5j  32  gm. 

Ferri  sulphat gt.  xvj  i  gm. 

Sodii  chloridi 3ss  2  gm. 

Acidi  sulphuric!  dil f5ij  8  c.c. 

Infus.  cascarillse f  5iv  120  c.c. 

M.  S. — Tablespoonful  before  breakfast,  diluted. 

When  emesis  fails  to  relieve  the  condition,  or  is  contraindicated, 
antispasmodics  and  vasodilators  may  be  tried.  Atropine  in  large 
doses  (gr.  ^50  hypodermatically),  or  nitroglycerin  (gr.  Koo  hypo- 
dermatically)  is  probably  the  most  useful  for  this  purpose.  Amyl 
nitrite,  by  inhalation,  is  especially  valuable  in  those  cases  where 
there  is  much  edema  about  the  face  and  neck.  It  is  peculiar  in  its 
action,  relieving  the  spasms  only  in  the  head,  neck,  and  upper  part  of 
the  chest,  and  should  prove  extremely  useful  in  those  distressing  cases 
where  there  is  an  edema  of  the  tongue,  pharynx,  or  glottis.  In  this 
condition  a  most  useful  adjunct  to  treatment  is  a  spray  of  adrenalin 
chloride.  Calcium  lactate,  in  a  single  dose  of  30  gr.  has  been  rec- 
ommended in  those  cases  which  are  supposed  to  be  due  to  the  inges- 
tion of  acid  fruit. 

Dr.  E.  B.  Finch  of  New  York  has  been  very  successful  in  the  treat- 
ment of  urticaria  by  the  use  of  creosote.  He  says:  "In  acute  toxic 
cases,  if  they  be  seen  early,  before  the  eruption  is  fully  developed,  the 
administration  of  creosote  may  greatly  modify  or  even  abort  an 
attack.  Four  minims  in  elastic  capsules  with  2  minims  in  enteric 
pill  should  be  given  for  an  initial  dose,  followed  every  fifteen  or  twenty 
minutes  with  2  minims  in  capsule  until  an  effect  is  produced.  In  the 
recurrent  or  chronic  forms  of  urticaria  creosote  may  lessen  the  fre- 
quency of  the  attacks  or  cause  them  to  cease  entirely.  After  each 
meal  and  before  retiring  from  2  to  6  minims  in  elastic  capsule  and  the 
same  amount  in  enteric  pill  should  be  given." 

Locally,  baths,  lotions,  or  dusting  powders  will  be  necessary  to  re- 
lieve the  itching.  Among  the  most  serviceable  measures  are: 
sponging  with  alcohol,  brandy,  whiskey,  carbolized  water,  or  witch 
hazel,  alkaline  baths,  and  acid  bath.  Duhring  recommends  the 
following: 

I^.     Acidi  carbolici 3jss  6  gm. 

Glycerini f  3ij  8  c.c. 

Alcoholis f  Sviij  240  c.c. 

Aq.  amygdal.  amar f  Bviij  240  c.c. 

M.  S. — Use  as  a  lotion  two  or  three  times  daily. 


66q  angioneurotic  edema 

Bulkley  suggests  the  following: 

I^.     Chloralis, 

Camphorae aa   5j  aa     4  gm. 

Misce,  and  incorporate  with 

pulveris  amyli §  j  to  ij  32  to  63  gm. 

M.     Keep  tightly  corked  in  a  wide- mouthed  bottle. 
S. — Rub  in  with  hand. 

A  serviceable  formula  is  the  following: 

I^.     Chloroformi f  5 j  4  c.c. 

Ung.  zinci  oxidi §ij  63  gm. 

M.  S. — Apply  locally. 
Or— 

I^.     Menthol gr.  v  0.32  gm. 

Petrolat §  j  32  .  o    gm. 

M.  S. — Apply  locally. 
Or— 

I^.     Acid  benzoic gr.  x  0.6  gm. 

Alcohol f §j  30.0  c.c. 

M.  S. — Apply  locally. 

Urticaria  pigmentosa  begins  in  the  early  months  of  infancy  and 
is  characterized  by  buff-colored  wheals,  with  or  without  itching, 
that  persist  for  a  long  period  and  after  disappearing  leave  behind 
brownish  stains.  It  is  very  rare.  It  is  essentially  chronic  but  seldom 
lasts  until  puberty.  The  treatment  consists  of  internal  and  local 
medication  based  on  the  same  principles  as  are  employed  in  other 
varieties  of  urticaria. 

ANGIONEUROTIC  EDEMA 

Angioneurotic  edema  (also  known  as  Quincke's  disease)  is  a  neurotic 
condition  in  which  transient  circumscribed,  edematous  swellings 
appear  on  the  skin,  and  sometimes  on  the  mucous  membranes,  and 
disappear  after  a  variable  period  without  leaving  behind  any  struc- 
tural alterations.  It  arises  usually  without  obvious  cause  and  is  in 
all  probability  a  vasomotor  neurosis.  In  susceptible  individuals 
it  may  be  induced  by  certain  drugs  or  by  certain  articles  of  diet; 
in  some  cases,  it  seems  to  be  hereditary.  Recurrences  are  frequent, 
and  when  the  larynx  is  involved  the  affection  assumes  a  grave  aspect. 
The  Treatment  is  similar  to  that  of  urticaria. 


ECZEMA  66 1 


ECZEMA 


Synonyms. — Tetter;  salt  rheum;  scall. 

Definition. — A  non-contagious  inflammation  of  the  skin,  char- 
acterized by  any  or  all  of  the  results  of  inflammation,  at  once  or  in 
succession,  such  as  erythema,  papules,  vesicles  or  pustules,  accom- 
panied by  more  or  less  infiltration  and  itching,  terminating  in  a  serous 
discharge,  with  the  formation  of  crusts,  or  in  desquamation. 

Forms. — Acute;  subacute;  chronic. 

Varieties. — Eczema  erythematosum;  eczema  papulosum;  eczema 
vesiculosum;  eczema  pustulosum;  eczema  rubrum;  eczema  squamosum; 
eczema  fissum;  eczema  verrucosum;  eczema  sclerosum. 

Causes. — Eczema  attacks  persons  in  all  spheres — the  rich,  the  poor, 
the  infant  or  the  aged,  and  males  or  females.  Many  families,  es- 
pecially those  having  the  "catarrhal  predisposition  or  peculiarity  of 
constitution,"  seem  more  liable;  indeed,  it  appears  probable  that  a 
predisposition  to  eczema  may  be  transmitted  from  parent  to  child. 
Other  causes  are:  improper  food,  gastrointestinal  disorders,  imperfect 
elimination  of  products  of  waste,  intestinal  parasites,  dentition, 
deficient  urinary  secretion,  Bright's  disease,  diabetes,  functional  and 
organic  nerve  affections,  the  rheumatic  and  gouty  diathesis,  vaccina- 
tion, prolonged  contact  of  hot  fomentations,  contact  with  the  poison 
vine  (rhus  toxicodendron)  and  poison  tree  (rhus  venenata),  heat  and 
cold,  and  various  chemical  and  mechanical  irritants. 

Pathology. — Eczema  is  a  catarrhal  inflammation  of  the  skin — 
a  dermatitis,  with  superficial  serous  exudation.  There  is  first  hyper- 
emia, or  congestion  of  the  vessels  of  the  skin.  The  hyperemia  is 
soon  followed  by  a  serous  exudation.  If  the  superficial  exudation 
be  profuse  enough  to  form  small  drops,  and  if  the  epidermis  possess 
sufficient  resisting  power  not  to  give  way  immediately  before  it,  vesicles 
form,  producing  the  variety  known  as  eczema  vesiculosum;  if  the 
vesicles  contain  a  large  admixture  of  young  cells,  so  that  the  serum 
be  turbid,  yellow,  and  purulent,  the  vesicles  become  pustules,  termed 
eczema  pustulosum;  if  the  serous  exudation  be  not  sufficient  to  either 
elevate  or  break  through  the  epidermis,  instead  of  either  vesicles  or 
pustules  forming,  there  occur  dry  scales,  rising  from  the  reddened 
skin — eczema  squamosum.  When  the  exudation  is  sufficient  to 
detach  the  epidermis,  thus  exposing  the  red  and  moist  corium,  it  is 
termed  eczema  rubrum. 

In  chronic  eczema,  the  skin  is  subacutely  inflamed  and  is  very 
much  thickened,  hardened,  and  infiltrated  with  cells  which  extend 


662  ECZEMA 

throughout  the  entire  corium,  even  into  the  subcutaneous  connec- 
tive tissue.  The  papillae  are  enlarged  and  at  times  may  be  dis- 
tinguished with  the  naked  eye.  Pigmentation  may  take  place  in 
the  deep  layers  of  the  rete  and  in  the  corium,  especially  about  the 
vessels. 

Symptoms. — Eczema  is  the  most  common  of  all  cutaneous  affec- 
tions, with  symptoms  varying  in  accordance  with  the  particular 
variety  of  the  affection  and  the  location,  although  the  general  char- 
acteristics of  a  catarrhal  inflammation  are  present  in  all;  these  are 
redness,  either  limited  or  diffused;  heat,  of  the  part  affected;  swelling, 
the  result  of  the  serous  exudation,  giving  rise  either  to  a  discharge 
(weeping),  with  subsequent  crusting,  or  to  the  deposition  of  plastic 
material.  The  most  constant,  annoying,  and  troublesome  symptom 
is  the  itching,  or,  at  times,  burning,  which  varies  from  that  which  is 
simply  annoying  to  that  which  is  almost  unendurable. 

Eczema  runs  its  course  either  as  an  acute  affection,  lasting  a  few 
weeks,  not  to  return,  or  to  return  acutely  at  wide  intervals,  or,  as  is 
much  more  frequently  the  case,  it  assumes  a  chronic  state,  continuing 
with  more  or  less  variations  for  months,  years,  or  even  a  life-time. 
It  may  appear  upon  any  portion  of  the  body  or  involve  the  whole 
integument  {eczema  universale).  The  varieties  are  named  in  the 
order  the  lesions  assume  at  their  commencement. 

Eczema  Erjrthematostmi. — An  erythema  or  redness  of  the  surface, 
with  a  yellow  tinge.  The  size  of  the  macule  may  be  very  small  or 
quite  extensive,  with  irregular  outlines.  There  may  be  slight  swell- 
ing of  the  patch,  but  no  discharge  occurs  unless  it  be  where  two  sur- 
faces come  into  contact  {eczema  intertrigo),  as  about  the  genitalia. 
Cases  without  discharge  are  covered  after  a  few  days  with  a  thin 
film  of  dry,  exfoliating  epidermis  or  scale  {eczema  squamosum) .  When 
a  discharge  (weeping)  or  moisture  occurs,  it  is  followed  with  more 
or  less  crusting.  Intense  itching  is  a  constant  symptom.  The 
variety  occurs  most  frequently  on  the  face,  the  back  of  the  neck,  and 
the  genitalia. 

Eczema  Papulostmi,  or  Lichen  Simplex.— This  variety  of  eczema 
appears  in  the  form  of  small,  rounded  papules,  the  size  of  a  pin-head, 
of  bright-red  or,  at  times,  dark-red  color;  they  may  be  either  discrete 
or  confluent.  In  some  cases  all,  while  in  others  a  greater  or  less  num- 
ber, of  the  papules  pass  into  vesicles  and  run  much  the  same  course 
as  vesicular  eczema.  The  itching  is  of  the  most  intense  character, 
leading  to  severe  scratching,  by  which  the  summits  of  the  papules  are 


ECZEMA  663 

torn,  causing  them  to  bleed,  the  blood  forming  dark-red  crusts.  The 
arms  and  legs  are  most  often  involved. 

Eczema  Vesiculosum. — This  variety  begins  with  burning,  pain, 
redness,  and  swelling,  followed  by  the  eruption  of  an  immense  number 
of  minute  vesicles,  either  discrete  or  confluent,  rapidly  distending 
with  a  clear  or  yellowish  fluid  and  attended  with  intense  itching. 
Soon  the  vesicles  rupture,  the  fluid  rapidly  diffusing  over  the  surface 
and  drying  into  yellowish,  honey-like  crusts.  New  crops  of  vesicles 
soon  follow,  or  if  subsequent  vesications  do  not  occur,  the  fluid  rap- 
idly diffuses  over  the  excoriated  surface,  which  also,  in  turn,  dries  into 
large,  yellowish  crusts.  After  a  variable  time  the  various  symptoms 
gradually  subside.  Intense  itching  is  the  most  prominent  subjective 
symptom,  and  gives  rise  to  an  irresistible  desire  to  scratch.  All  por- 
tions of  the  body  are  liable  to  this  variety  of  eczema,  the  most  fre- 
quent location,  however,  being  the  face,  and  when  occurring  in  this 
region  in  children  is  commonly  known  as  crusta  lactea.  The  affec- 
tion is  very  chronic  and  recurrences  are  common.  It  often  terminates 
in  eczema  rubrum. 

Eczema  Pustulosmn,  or  Eczema  Impetiginosum. — This  form  usu- 
ally begins  as  vesicular  eczema,  the  fluid  rapidly  changing  to  pus. 
After  a  short  period,  during  which  the  pustules  have  increased  in 
size,  they  burst  and  the  escaped  fluid  forms  thick,  greenish-yellow 
crusts,  which,  in  turn,  rapidly  dry  and  fall  off,  or  crumble  away.  The 
location  of  this  variety  is  most  usually  upon  the  scalp  and  face.  It 
is  observed  most  often  in  poorly  nourished  and  unclean  children  and 
is  stubborn  to  treatment.     Itching  is  a  prominent  symptom. 

Eczema  Rubrum. — This  is  a  variety  only  from  a  clinical  standpoint. 
It  may  result  from  any  of  the  foregoing  varieties.  The  surface  of  the 
skin  is  inflamed  and  infiltrated,  red,  moist,  and  weeping,  the  profuse 
serum  rapidly  drying  into  thick,  yellowish,  greenish,  or  brownish 
crusts,  the  color  depending  upon  the  character  of  the  fluid,  which  may 
be  serum,  pus,  or  blood  from  the  exposed  and  lacerated  corium.  The 
crusts  adhere  closely  and  firmly  to  the  part,  and  unless  removed 
by  mechanical  means  may  remain  indefinitely,  the  disease  pursuing 
its  course  beneath.  Eczema  rubrum,  or  madidans,  "presents  two 
appearances — as  it  occurs  with  its  crust,  and  as  it  exists  without  this 
covering.  In  the  one  case  the  skin  itself  is  altogether  obscured  by  a 
dirty,  yellowish,  or  brownish  crust;  in  the  other  the  skin  presents  a 
bright  or  violaceous  red,  punctate,  wounded  surface,  deprived  in 
great  part  of  its  epidermis,  and  exuding  a  scanty  or  profuse,  clear  or 


664  '■  ECZEMA 

Opaque,  syrupy,  yellowish  fluid.  Sometimes  this  is  streaked  with 
blood."  The  itching  and  burning  are  severe.  It  may  develop  upon 
any  portion  of  the  body,  but  is  most  commonly  seen  upon  the  legs, 
particularly  in  elderly  people,  and  on  the  face  in  infants.  Its  course 
is  chronic  and  tends  to  increase  in  severity. 

Eczema  Squamosum. — This  is  also  a  clinical  variety.  It  occurs 
as  the  terminal  stage  of  the  erythematous,  vesicular,  pustular,  or  papu- 
lar varieties  of  the  affection,  but  more  particularly  the  first  named. 
A  typical  case  presents  itself  in  the  form  of  variously  sized,  and  shaped 
reddish  patches,  which  are  dry,  or  more  or  less  scaly,  the  skin  being 
more  or  less  infiltrated  or  thickened.  When  occurring  at  the  flexures 
of  the  body  the  skin  is  liable  to  become  fissured.  Its  course  is  usually 
chronic. 

Eczema  Fissum,  or  Rimosum. — A  clinical  variety,  in  which,  during 
the  progress  of  the  erythematous,  vesicular,  or  pustular  varieties  of 
eczema,  cracks  or  fissures  result  when  the  lesion  occurs  upon  regions 
subject  to  constant  motion,  such  as  between  the  fingers,  toes,  nates, 
and  the  various  joints.  At  times  the  fissures  are  extensive  and  deep, 
and  of  a  bright-red  color,  showing  the  true  skin,  and  intensely  painful 
upon  motion.     Chapped  hands  are  typical  instances  of  fissured  eczema. 

Eczema  Sclerostmi. — This  clinical  variety  of  eczema,  occurring 
most  commonly  on  the  palms,  soles,  and  finger-tips,  is  characterized 
by  hypertrophy  of  the  papillae,  showing  itself  as  hard,  thickened, 
infiltrated,  localized  patches,  which  are  very  liable  to  crack  (eczema 
fissum) . 

Eczema  Verrucosum,  or  Papillomatosimi,  differs  from  the  foregoing 
in  that  the  thickened,  infiltrated  patch  has  a  warty,  verrucous  appear- 
ance.    Its  course  is  chronic. 

Acute  and  Chronic  Eczema. — The  line  which  divides  these  two  con- 
ditions is  drawn  by  means  of  the  clinical  and  pathological  features. 
The  course  of  eczema,  in  the  majority  of  instances,  is  chronic.  It 
may  be  said  that  so  long  as  the  general  inflammatory  symptoms  are 
high  and  the  secondary  changes  slight,  the  affection  is  acute,  and  that 
when  the  process  has  settled  itself  into  a  definite  line  of  action,  contin- 
ually repeating  itself  and  accompanied  by  secondary  changes,  it  is 
chronic. 

Diagnosis. — The  many  varieties  in  which  eczema  manifests  itself 
render  the  diagnosis  a  matter  of  importance.  The  following  char- 
acteristic features  of  eczema  are  of  value  in  arriving  at  a  diagnosis: 
Inflammation,  redness,  swelling,  edema,  thickening  from  cell  infiltra- 


ECZEMA  665 

tion,  serous  exudation  followed  by  crusting,  on  the  removal  of  which 
a  moist  surface  is  exposed,  absence  of  a  sharp  line  of  demarcation 
between  the  diseased  area  and  the  healthy  skin,  polymorphism  of  the 
lesions,  and  marked  itching  and  burning. 

Erysipelas  may  be  confounded  with  erythematous  or  vesicular 
eczema.  The  points  of  difference  are  the  fever  and  other  general 
disturbances.  The  deep-seated  inflammation  of  the  skin,  rapidly 
spreading,  with  heat,  swelling,  and  edema  without  moisture,  giving 
the  surface  a  deep-red,  shining,  and  tense  appearance,  are  character- 
istic of  erysipelas  and  serve  to  distinguish  it  from  eczema. 

Herpes  zoster  may  be  confused  with  vesicular  eczema,  but  in  the 
former  the  eruption  is  preceded  by  neuralgic  pains  over  the  affected 
areas,  vesicles  form  in  groups  along  the  course  of  superficial  nerves  and 
are  large  and  tense,  showing  no  tendency  to  spontaneous  rupture,  the 
eruption  is  unilateral,  and  the  course  is  definite;  all  of  which  features 
are  absent  in  vesicular  eczema. 

Scabies  often  resembles  eczema,  especially  those  cases  in  which  the 
resulting  dermatitis  is  severe.  A  distinction  here  is  of  the  utmost 
importance  as  the  apparent  eczema  may  persist  indefinitely  unless 
the  true  cause  be  promptly  ascertained.  In  scabies  the  eruption  is 
distributed  to  the  flexor  surfaces  of  the  body,  the  webs  of  the  fingers, 
axillae,  mammary  glands,  buttocks,  penis  and  inside  surfaces  of  the 
legs  and  thighs;  the  face  is  exempt  except  in  nursing  infants;  the 
itching  is  worse  at  night;  there  is  a  history  of  contagion;  and  the 
burrows  and  itch-mite  may  be  detected.  Eczema  has  no  character- 
istic distribution,  is  not  contagious;  the  itching  is  constant,  and  there 
are  no  burrows  or  itch-mites. 

Impetigo  contagiosa  may  be  at  times  mistaken  for  pustular  eczema, 
the  points  of  distinction  being :  In  impetigo  there  is  a  history  of  con- 
tagion; the  lesions  first  appear  as  discrete  vesicles  or  blebs,  the  con- 
tents of  which  rapidly  become  purulent  and  soon  fiat,  loosely- 
attached  crusts  form.  The  lesions  are  superficial  and  disappear 
within  one  or  two  weeks.  Itching  is  very  slight.  In  eczema  there 
is  a  diffuse  deep  inflammatory  base;  the  affection  is  non-contagious, 
and  the  course  very  chronic. 

Sycosis  vulgaris  may  be  distinguished  from  eczema  by  its  localiza- 
tion to  the  hair-follicles,  the  interfoUicular  skin  being  free,  and  by  its 
great  tendency  to  recur. 

Psoriasis  may  be  readily  differentiated  from  eczema  by  its  location 
(elbows,  knees,  scalp),  the  presence  of  round,  sharply  marginated 


666  ■  ECZEMA 

patches  abundantly  covered  with  imbricated,  silvery,  mother-of-pearl 
scales,  the  absence  of  infiltration,  thickening,  and  discharge  so  char- 
acteristic of  eczema,  and  the  very  chronic  course. 

Tinea  circinata  and  squamous  eczema  may  simulate  each  other. 
The  former  is  characterized  by  its  circinate,  sharply  defined  patches, 
clearing  in  the  center  and  spreading  on  the  periphery,  its  contagious 
nature,  and  the  presence  of  the  trichophyton  fungus  in  the  scales, 
demonstrable  by  the  microscope.  In  eczema,  the  patches  are  irregu- 
lar, not  well  defined,  and  do  not  tend  to  clear  in  the  center.  It  is 
not  contagious  and  there  is  no  fungus  present  in  the  scales. 

Seborrhea  of  the  scalp  and  squamous  eczema  of  the  same  region 
closely  resemble  each  other.  In  eczema,  however,  the  skin  is  more 
or  less  red,  inflamed,  and  thickened,  and  the  scales  larger,  less  abun- 
dant and  less  greasy  and  drier  than  in  seborrhea.  In  eczema  the  scales 
are  usually  seated  in  a  circumscribed  patch,  while  in  seborrhea,  as 
a  rule,  they  cover  the  scalp  uniformly.  Itching  occurs  with  both 
disorders.  This  history  of  the  two  affections  should  be  of  material 
aid  in  rendering  the  diagnosis  clear;  still,  however,  in  many  cases 
the  diagnosis  is  difficult.     Both  are  frequent  affections. 

Treatment. — There  is  no  specific.  The  indications  are  to  remove 
the  cause  if  possible,  to  maintain  the  general  health,  and  to  apply 
such  substances  to  the  diseased  area  as  will  induce  involution  of  the 
inflammatory  process.  The  diet  should  be  given  most  careful  at- 
tention as  frequently,  particularly  in  children,  errors  in  this  direction 
are  most  potent  etiological  factors.  Tea,  coffee,  alcoholic  beverages, 
sugar,  candies,  pastries,  starchy  foods,  fried  meats,  condiments,  etc., 
should  be  interdicted  or  at  least  reduced  to  a  minimum.  Substances 
which  the  patient  is  aware  do  not  agree  with  him  should  of  course  be 
avoided.  Fresh  air  and  moderate  exercise  are  essentials  in  the 
treatment  together  with  attention  to  the  secretions,  particularly 
of  the  kidneys.  Sluggish  action  of  the  bowels  should  be  avoided 
by  the  use  of"  such  mineral-spring  waters  as  the  Hunyadi  Janos,or 
a  morning  dose  of  magnesium  sulphate.  The  "acid  mixture  of  iron" 
is  of  great  value  in  this  connection: 

I^.     Ferri  sulphatis gr.  viij  0.51  gm. 

Magnesii  sulphatis §jss  47 -O    gm. 

Acid  sulphuric,  dilut TTllxxx  5.0    c.c. 

Tr.  cardamom,  comp. 

q.  s.  ad  fgiv  120.0    c.c. 

M.    S. — One    tablespoonful    in    water,    half   an   hour   before 
breakfast. 


ECZEMA  667 

For  children,  equal  parts  of  aromatic  syrup  of  rhubarb  and  castor 
oil  make  an  excellent  laxative  mixture.  The  addition  of  magnesia 
to  syrup  of  rhubarb  may  be  employed.  Calomel  and  soda  is  a  useful 
combination. 

If  the  urinary  secretion  be  small  and  the  urine  heavy,  full  doses 
of  potassium  acetate  and  large  draughts  of  water  should  be  used. 
If  either  a  rheumatic  or  gouty  tendency  exists,  the  salicylates,  lithium 
salts,  or  colchicum  should  be  employed.  If  there  is  any  scrofulous 
or  tuberculous  tendency  cod-liver  oil  and  syrup  of  iodide  of  iron  should 
be  prescribed  in  addition  to  fresh  air,  sunlight,  regulated  exercise, 
etc.  In  anemic  individuals,  iron,  quinine,  strychnine,  mineral  acids, 
syrup  of  the  hypophosphites,  and  small  doses  of  corrosive  sublimate 
are  indicated.  Arsenic  is  usually  contraindicated  in  eczema,  its  field 
of  usefulness  being  limited  to  those  cases  occurring  in  weak,  anemic, 
debilitated,  neurotic  individuals.  It  has  no  direct  bearing  upon  the 
disease  itself.  Potassium  iodide,  internally,  frequently  aids  in  re- 
ducing the  infiltration  in  chronic  thickened  eczemas  even  in  the 
absence  of  syphilis. 

Locally,  the  first  step  in  the  treatment  is  to  remove  all  forms  of 
existing  irritation.  It  may  be  stated  as  a  principle,  that  nothing 
irritant  is  ever  to  be  applied  to  the  surface  in  acute  eczema  and  that 
in  chronic  eczema,  stimulation  is  indicated.  Soap  and  water  are  to 
be  avoided  on  areas  the  seat  of  acute  eczema.  For  cleansing  purposes, 
water  containing  boric  acid,  bran,  starch,  or  oatmeal,  may  be  employed. 
In  chronic,  thickened,  and  indurated  eczema,  soap  is  often  of  value 
as  a  stimulant.  Crusts  and  scales  are  nearly  always  present  in  eczema 
and  must  first  be  removed  to  obtain  the  best  results  from  local 
applications.  This  may  be  readily  accomplished  by  saturation  with 
oily  preparations,  a  starch  or  other  mild  poultice,  a  saturated  solution 
of  boric  acid,  or  dilute  boroglycerin.  Pastes  and  ointments  may  be 
easily  removed  by  first  softening  with  olive  oil,  sweet  oil,  or  petro- 
latum.    Soap  and  water  should  not  be  used  for  either  purpose. 

Acute  Eczema. — If  the  type  of  disease  is  vesicular,  dusting  powders, 
such  as  magnesium  carbonate,  boric  acid,  bismuth  subnitrate,  starch, 
zinc  oxide,  talcum,  etc.,  may  be  employed  with  advantage  in  the 
early  stage.     The  following  may  also  be  used: 

I^.     Pulv.  camphorae 5j  4  gm. 

Zinc  cleat 3ij  8  gm. 

Pulv.  amyli 5  j  32  gm. 

M.  S. — Dusting  powder. 


668  "  ECZEMA 

J.  C.  White  recommends  bathing  the  part  with  loHo  nigra  full 
strength  or  diluted  with  lime-water,  applied  by  means  of  a  sponge 
or  a  piece  of  cloth  for  ten  or  fifteen  minutes  at  a  time,  and  at  intervals 
of  a  few  hours  or  longer,  the  sediment  being  allowed  to  dry  on  the 
skin,  after  which  ointment  of  zinc  oxide  should  be  gently  rubbed 
over  the  part.  As  a  rule,  the  itching  and  burning  are  promptly 
relieved  and  the  affection  often  arrested. 

I^.     Hydrarg,  chlorid  mit gr.  viij  0.5  gm. 

Liquor  calcis f §j  30.0  c.c. 

M.  S. — ^Lotio  Nigra.     Apply  locally  as  directed. 

Stelwagon  employs  the  boric-acid  lotion,  15  gr.  (i  gm.),  to  the 
ounce  (30  c.c),  followed  by  applications  of  ointment  of  zinc  oxide 
in  vesicular  eczema  and  the  following  compound  lotion  in  erjrthema- 
tous  and  papular  types : 

I^.     Acidid.  boric 5ij  8  gm. 

Acid,  carbolici 5ss  2  gm. 

Glycerin TTlx  to  xxx  o  .65  to  2  c.c. 

Aqu^ q.  s.  ad  Oss  250  c.c. 

M.  S. — Apply  locally  twice  daily. 

This  may  be  used  alone  or  followed  by  an  ointment  or  a  dusting 
powder.  Lotions  containing  an  excess  of  the  substance  in  solution 
are  of  value  by  the  sediment  they  leave  behind,  which  acts  as  a  dust- 
ing powder.  The  calamine  and  zinc  oxide  lotion  may  be  taken  as  an 
example : 

I^.     Calamini, 

Zinc  oxidi aa   5ij  to  iv        8  to  16  gm. 

Liquor  calcis ^  f  §ij  60  c.c. 

Aquae  vel  solut.  acid. 

boric,  saturat q.  s.  ad  Oss  250  c.c. 

M.  S. — Apply  locally  several  times  daily  (Stelwagon). 

The  following  lotion  is  employed  extensively  in  acute  cases  by 
Hartzell : 

I^.     Resorcin 5ss  2  gm. 

Bismuth  subnitrat 5ij  8  gm. 

Glycerin 5ij  8  c.c. 

Liq.  calcis q.  s.  ad  f  Biv  120  c.c. 

M.  S. — Apply  locally  twice  daily. 


ECZEMA  669 

Some  cases  do  better  on  ointments  such  as — 

I^.     Zinci  oleat 5iv  16  gm. 

Olei  olivae fSiv  16  c.c. 

M.  Ft.  unguentum. 

S. — Apply  locally  twice  daily. 

Or,  bismuth  oleate,  made  according  to  the  following  formula  of 
McCall  Anderson: 

I^.     Bismuthi  oxidi Sj  4-0    g"i- 

Acidi  oleici 5j  30.0    gm. 

Ceras  albas Sii]  12.0    gm. 

Vaselini 5ix  36.0    gm. 

01.  rosae lUij  o.  12  c.c. 

M.  S. — Use  locally  as  directed. 

If  the  discharge  be  excessive,  the  following  formula  of  Bartholow 
is  valuable: 

I^.     Plumbi  acetat .  gss  16  gm. 

Pulv.  camphorae gr.  xv  i  gm. 

01.  amygdal f  oij  60  c.c. 

Cerat.  flav 5  j  32  gm. 

M.  S. — For  local  application. 

Pastes  are  often  of  value,  of  which  Lassar's  paste  may  be  taken 
as  a  type: 

I^.     Pulv.  amyli, 

Pulv.  zinci  oxid aa   51]  8  gm. 

Petrolat Bss  16  gm. 

M.   S. — Apply  to  affected  area  twice  daily;  using  sweet  oil 
or  petrolatum  to  remove  the  same  before  applying  fresh  paste. 

This  may  be  used  alone  or  in  combination  with  boric  acid  or  sali- 
cylic acid  or  it  may  be  rendered  more  soft  by  the  addition  of  an 
equal  quantity  of  petrolatum.  Diachylon  ointment,  made  by  the 
formula  of  Hebra  or  by  melting  4  parts  of  lead  plaster  and  2  or  3 
parts  of  olive  oil,  is  also  very  efficacious. 

In  pustular  eczema,  the  following  is  of  great  benefit : 

I^.     Hydrarg.  ammoniat gr.  xx  1.3  gm. 

Petrolat §j  32  .0  gm. 

M.  S. — Apply  locally. 


670  -•  ECZEMA 

For  eczema  papulosum  the  following  lotions  are  particularly 
valuable : 

I^.     Acidi  carbolici 5i  to  ij         4  to  8  gm. 

Glycerini f  5iv  16  c.c. 

Alcoholis f  5iv  to  vj  16  to  24  c.c. 

Aquae  destil q.  s.  ad  Oj  ad  480  c.c. 

M.  S. — Apply  locally  (Duhring). 
Or— 

I^.     Thymol gr.  xv  i  gm. 

Alcoholis f  5j  30  c.c. 

Aquae  destil f gj  30  c.c. 

M.  S. — Apply  locally. 

To  relieve  the  itching  incident  to  acute  eczema,  carbolic  acid, 
menthol,  and  preparations  of  tar  may  be  added  to  the  preceding 
formulas  but  in  very  weak  strength  in  order  to  avoid  inducing 
additional  irritation. 

After  the  disappearance  of  the  acute  symptoms,  the  applica- 
tions should  be  more  stimulating  and  should  include  carbolic  acid, 
thymol,  tar,  oil  of  cade,  and  similar  substances.  It  is  to  be  remem- 
bered, however,  that  the  more  chronic  the  affection  and  the  less 
violent  the  inflammatory  symptoms  the  more  successful  is  tar  in 
this  disease.  Furthermore,  it  should  be  borne  in  mind  that  the 
dosage  of  external  medication  is  subject  to  great  variations  in  dif- 
ferent individuals  and  it  is  always  best  to  begin  with  a  very 
weak  ointment  or  lotion,  watching  the  effects  while  the  strength 
is  being  increased.  Unless  this  precaution  is  taken  the  disease  is 
likely  to  be  aggravated.     The  following  is  of  value  in  subacute  cases : 

I^.     Liq.  carbonis  detergent. ...    §ss  to  ij      16  to  64  c.c. 

Aquae Oi  480  c.c. 

M.  S. — Poison;  for  external  use  only. 

Duhring  considers  the  following  one  of  the  most  elegant  of  the 
tar  ointments: 

I^.     Olei  cadini fSJss  6.0  c.c. 

Cerati  simplicis §  j  32  .0  gm. 

01.  amygdal  amar gtt.  x  0.6  c.c. 

M.  Ft.  ungt. 
S. — Apply  as  directed. 
Or— 


ECZEMA  671 

T\.     Picis  liquidae f  5J  4  c.c. 

Glycerini f  5J  4  c.c. 

Alcoholis f  5vj  24  c.c. 

01.  amygdal,  amar gtt.  xv  i  c.c.  • 

M.  S. — To  be  rubbed  firmly  into  the  skin. 

The   following   is    Bulkley's    valuable    "liquor   picis    alkalinus:" 

I^.     Picis  liquidse :  .  .  .   f  5ij  8  c.c. 

Potassag  causticse 5j  4  grn- 

Aquae  destillatse f  3v  20  c.c. 

The  potash  to  be  dissolved  in  water  and  gradually  added  to 
the  tar  with  rubbing  in  a  mortar. 
M.  S.— To  be  used  diluted. 

Chronic  Eczema. — In  this  variety  the  treatment  varies  according 
as  the  affected  area  is  weeping  or  is  dry,  hard,  and  sclerosed.  The 
weeping  and  discharging  eczemas  while  chronic  as  regards  time  are 
usually  acute  in  type  and  require  sedative  or  moderately  stimulating 
applications  until  the  discharge  has  been  reduced.  In  the  dry,  in- 
filtrated, and  thickened  varieties,  stimulation  is  necessary.  The 
following  is  of  value:  • 

I^.     Olei  cadini 5  J  4-0    gm. 

Acid,  salicyl gr.  x  0.65  gm. 

Pulv.  amyli, 

Pulv.  zinc  oxidi aa   3ij  8.0    gm. 

Petrolat 3iv  16.0    gm. 

M.  S. — Apply  locally  twice  daily. 

The  following  ointment,  technically  known  as  "unguentum  diachyli 
albi  of  Eehra,'"  has  been  successful  in  a  number  of  cases  of  chronic 
eczema  of  the  legs.     The  formula  is: 

I^.     Emplast.  plumbi, 

Vasehni aa   5  J  aa    32  gm. 

01.  lavandulse q.  s.  q.  s. 

Dissolve  with  heat  and  stir  till  cold. 
M.  S. — Apply  on  strips. 

The  application  of  an  elastic  webbing  bandage  (not  the  ordinary 
rubber  bandage)  to  the  affected  leg  in  cases  of  eczema  unattended  by 
dicharge  is  often  of  great  benefit.  The  support  afforded  by  a  gelatin 
dressing  commends  its  use  but  it  is  contraindicated  when  there  is  any 
active  discharge.     The  following  is*used  extensively: 


672  ■  ECZEMA 

I^.  Zinc,  oxid, 

Gelatin aa  30  parts 

Glycerin 50  parts 

Aquae 90  parts 

M.  S. — The  application  is  melted  on  a  water-bath  and  the 
temperature  is  allowed  to  fall  until  it  is  near  that  of  the  body, 
after  which  it  is  thickly  painted  on  the  already  cleaned  affected 
area.  It  is  then  strewn  with  a  powder  or  absorbent  wool  dabbed 
on  to  facilitate  the  hardening  process  (Whitfield) . 

DaCosta  claims  to  have  had  excellent  results  in  the  treatment  of 
eczema  rubrum  from  the  internal  administration  of  the  solution  of 
arsenic  and  the  iodide  of  mercury  (Donovan's  solution),  ITlij  to  v 
(0.12  to  0.3  c.c),  in  water  after  meals  and  the  local  application  of  the 
following : 

I^.     Ung.  plumbi  subacet 5iv  16.0  gm. 

Acid,  carbolici  cryst gr.  iij  0.2  gm. 

Petrolat 5iv  16.0  gm. 

M.  S. — Apply  freely  on  muslin  strips. 

TREATMENT  OF  SPECIAL  FORMS  AND  VARIETIES  OF 

ECZEMA 

The  principles  upon  which  eczema  is  treated  admit  of  no  variation, 
no  matter  in  what  region  the  disease  is  encountered,  but  the  form  of 
irritation  to  which  the  affection  is  usually  due  differs  in  different  parts 
of  the  body  and  requires  more  than  passing  mention. 

Universal  eczema  arises  either  as  the  result  of  grave  internal  dis- 
orders, especially  in  children,  or  from  generalized  irritation  such  as 
accompanies  the  parasitic  affections  and  attends  certain  occupations. 
Obviously  the  removal  of  the  cause  in  these  cases  brings  about  subsi- 
dence of  the  eczema. 

Eczema  capitis  is  either  erythematous,  vesicular,  or  pustular  in 
character.  If  the  first  named,  it  at  once  tends  to  become  chronic, 
settling  into  the  variety  known  as  eczema  squamosum,  often  involv- 
ing the  entire  scalp  and  accompanied  by  intense  itching.  The 
pustular  variety  is  the  more  common  form,  occurring  upon  the  scalp 
of  children  and  young  adults,  existing  as  a  few  patches,  or,  what  is 
more  frequent,  involving  the  entire  scalp.  The  pustules  soon  rupture, 
the  liquid  drying  into  greenish-yellow  crusts,  often  covering  the  whole 
scalp  with  a  cap  or  crust.     The  hair  becomes  matted  and  caked,  the 


ECZEMA  673 

sebaceous  secretions  collect,  and  if  the  part  is  not  cleansed,  becomes 
offensive.  In  severe  cases  of  pustular  eczema  of  the  scalp  enlarge- 
ment of  the  lymphatic  glands  of  the  back  of  the  neck  and  of  those 
behind  the  ear  occur;  but  they  never  suppurate.  Pediculi  are  fre- 
quently associated  with  eczema  capitis  in  children,  either  as  a  primary 
cause  or  a  result  of  the  matted  condition  of  the  hair  which  constitutes 
a  favorable  habitat  for  them.  Care  should  always  be  taken  not  to 
confuse  eczema  of  the  scalp  with  psoriasis,  seborrhea,  syphilis,  tinea 
favosa,  and  tinea  tonsurans. 

Treatment. — In  the  pustular  variety  the  crusts  should  first  be  re- 
moved by  saturation  with  olive  oil  or  oil  of  sweet  almond  and  washing 
with  warm  water  and  soap,  or  the  use  of  a  starch  poultice  or  a  25  per 
cent,  solution  of  boroglycerin.  It  should  be  borne  in  mind  that  neg- 
lect is  responsible  for  a  great  many  of  these  cases.  DaCosta  rec- 
ommends the  following  application  after  removal  of  the  crusts : 

I^.      Hydrargyri  chlor.  mitis. .  .  .  gr.  xx  1.3  gm. 

Acid,  carbol.  cryst gr-  iij  0-2  gm. 

Petrolat B  j  32.0  gm. 

M.  S. — Apply  thoroughly. 

In  cases  associated  with  pediculi  or  succeeding  impetigo  contagiosa 
the  following  is  of  great  benefit : 

I^.     Hydrargyri  ammoniat gr.  x  to  xx  o .  65  to  i .  3  gm. 

Adipis  benzoat 5j  32  .0  gm. 

M.  S. — Apply  locally. 

For  the  squamous  variety  of  the  scalp,  the  following  formula, 
recommended  by  Duhring  is  excellent : 

I^.      Picis  liquidae f  3j  4  c.c. 

Glycerini.  . f  oj  4  c.c. 

Alcoholis f  5vj  24  c.c. 

01.  amygdalae  amar gtt.  xv  i  c.c. 

M.  S. — Diluted  or  full  strength,  rubbed  thoroughly  into  the 
scalp. 

Other  applications,  such  as  boric-acid  lotion,  oxide  of  zinc  ointment, 
etc.,  previously  advised,  may  also  be  used  with  the  exception  of  the 
pastes,  which  are  extremely  difficult  to  remove  from  the  hair.  A 
word  of  caution  may  be  given  regarding  resorcin  lotions  in  eczema 
of  the  scalp.  In  brunettes  such  applications  may  be  used,  but  in 
43 


674  *  ECZEMA 

blondes  the  hair  is  apt  to  assume  various  shades  as  a  result  of  the 
application. 

In  all  cases  cleanliness  is  essential.  The  diet  should  be  carefully 
regulated  and  tonics  should  be  administered  if  the  patient's  condition 
is  one  of  general  debility. 

Eczema  Faciei. — In  this  location  the  affection  may  be  either  acute 
or  chronic.  In  adults  the  erythematous  variety  is  frequently  en- 
countered in  patches  about  the  forehead  and  cheeks.  It  usually 
results  from  irritation  such  as  accompanies  exposure  to  heat  and  cold 
and  contact  with  strong  soaps,  etc.  Eczema  of  the  face  is  more 
common  in  children,  however,  the  varieties  being  the  vesicular  and 
pustular.  It  is  seen  on  the  forehead,  nose  and  upper  lip,  and  is 
associated  with  severe  itching.  The  primary  cause  in  most  cases  is 
to  be  found  in  disturbances  of  digestion  although  the  condition  may 
be  greatly  aggravated  by  attempts  at  treatment  by  -members  of 
the  family. 

Treatment. — The  cause  should  be  promptly  removed.  The  diffi- 
culty with  which  determination  of  the  cause  is  attended  should  lead 
the  physician  to  regulate  the  diet,  as  already  given,  and  interdict  the 
local  use  of  soap  and  water  routinely.  The  application  of  a  mild  seda- 
tive lotion  such  as  a  saturated  solution  of  boric  acid  should  be  pre- 
scribed at  first  until  the  true  condition  of  the  disease  is  asserted. 
In  erythematous  eczema  of  the  face  lotions  seem  most  beneficial; 
in  vesicular  and  pustular  forms,  soft  ointments  and  pastes  are  valuable. 
Late  in  all  forms  of  facial  eczema  pastes  are  of  great  service.  The 
following  is  also  useful: 

I^.     Zinc,  cleat 5j  4  gm. 

Petrolat B  j  32  gm. 

^  M.  S. — Apply  locally. 

Eczema  Labiorum. — Eczema  attacks  the  lips,  either  alone  or  in 
connection  with  other  parts  of  the  face.  One  or  both  lips  may  be 
affected.  The  irritation  of  the  tooth  brush  or  tooth  powder  may  be 
the  cause.  The  symptomxS  are  swelling,  redness,  heat,  infiltration, 
slight  scaliness,  and  fissures.  The  affection  may  be  in  the  skin 
around  the  border  of  the  mouth,  or  the  vermilion  and  mucous  mem- 
brane of  the  lips.  The  mouth  may  be  contracted  and  the  lips  partly 
glued  together  by  the  exudation  and  crusts.  Eczema  labiorum  may 
be  confounded  with  herpes  labialis  and  syphilis. 

Treatment. — This  is  very  difficult  and  inconvenient  to  the  patient. 
Among  the  remedies  at  times  successful  may  be  mentioned  silver 


ECZEMA  675 

nitrate,  potassium  nitrate,  carbolic  acid,  boric  acid,  or  tar  in  solution 
or  ointment,  and  flexible  collodion.  A  combination  of  boric  acid, 
acetanilide,  and  bismuth  is  often  of  value.  Tragacanth,  acacia,  and 
gelatin  paints  are  also  used  and  should  be  applied  with  the  lips  apart, 
otherwise  the  dressing  cracks  when  the  mouth  is  opened. 

Eczema  Palpebrarum. — This  is  a  rather  common  occurrence  in 
scrofulous  children,  showing  itself  along  the  edge  of  the  eyelids. 
It  is  frequently  accompanied  by  conjunctivitis.  It  may  be  due  to 
the  congestion  that  attends  eye-strain.  Pediculosis  ciliarum  is  an 
occasional  cause.  Pustules  form  at  the  openings  of  the  hair  follicles 
and  the  lids  become  crusted.  Swelling,  redness,  and  itching  are 
present  and  unless  the  parts  are  frequently  cleansed,  the  lids  will 
become  glued  together. 

Treatment. — The  discharge  incident  to  any  existing  conjunctivitis 
should  be  removed  and  any  ocular  condition  present  should  be  treated. 
Yellow  oxide  of  mercury,  gr.  j  (0.065  g"^-)?  in  petrolatum,  3ij  (8 
gm.),  rubbed  into  the  roots  of  the  eyelashes  every  night  is  very- 
beneficial.  The  oleate  of  zinc  and  the  glycerite  of  tannic  acid  are 
also  valuable. 

In  severe  cases  the  plan  recommended  by  McCall  Anderson 
should  be  pursued.  It  consists  in  the  extraction  of  the  eyelashes 
and  touching  the  edges  of  the  lids  with  a  solution  of  potassium  in 
water,  10  gr.  to  the  ounce.  The  edges  should  be  carefully  dried  and 
the  lid  everted,  a  very  small  quantity  on  a  delicate  brush  being  ap- 
plied, immediately  neutralizing  the  alkali  with  acetic  acid  or  vinegar. 

Eczema  Narium. — This  also  occurs  most  often  in  children  and 
appears  as  the  pustular  form  of  the  disease.  Nasal  catarrh  and 
general  malnutrition  are  the  most  important  etiological  factors. 
These  should  first  receive  attention,  after  which  the  treatment  ad- 
vised for  pustular  eczema,  elsewhere,  is  applicable. 

Eczema  Barbce. — Eczema  of  the  beard  is  characterized  by  the 
formation  of  extensive  pustules,  showing  a  preference  for  the  skin 
about  the  hairs,  drying  as  yellowish  or  greenish  crusts,  matting  the 
hairs  together  and  adhering  to  the  parts.  The  affection  may  be  con- 
fined to  the  hairy  portions  of  the  face,  or  extend  to  other  regions  of 
face,  localized  or  general,  acute  or  chronic. 

Eczema  ^  barbae  in  its  general  features  somewhat  resembles  both 
tinea  sycosis  and  sycosis  non-parasitica,  but  sycosis  is  an  inflam- 
mation of  the  hair-follicles  only  and  is  rarely  associated  with  crusting, . 
while  crusting  is  abundant  in  eczema. 


676  ■  ECZEMA 

Treatment. — The  hair  should  be  kept  very  short  by  clipping  with 
scissors;  when  the  inflammation  has  subsided  somewhat,  shaving 
closely  is  indicated.  Sedative  lotions  and  ointments  are  to  be  used 
at  first.  The  crusting  should  be  removed  by  oil  or  petrolatum  but 
not  by  soap  and  water,  if  the  inflammation  is  acute.  In  chronic 
cases  the  following  ointment  should  be  applied  after  cleansing  and 
shaving  the  beard: 

I^.     Hydrargyri  ammoniat gr.  xv  to  xxx  i  to  2  gm. 

Sulphur,  prascipitati 5ss  to  j  2  to  4  gm. 

Petrolat 5j  32           gm. 

M.  S. — To  be  thoroughly  applied. 

As  in  other  forms  of  eczema,  internal  treatment  may  be  of  value. 
The  solution  of  arsenic  and  iodide  of  mercury  (Donovan's  solution), 
TUij  to  V  (0.13  to  0.3  c.c),  three  or  four  times  daily,  is  often  of  benefit. 

Eczema  Aurium. — Eczema  of  the  ears  may  be  either  erythematous, 
vesicular,  or  pustular.  If  the  former,  thickening  results,  with 
desquamation  of  flakes  or  large  scales;  if  either  of  the  latter,  crusts 
form  which  may  envelop  the  whole  ear,  the  symptoms  being  swelling, 
redness,  and  severe  burning  and  itching  and  if  the  process  extend  into 
the  meatus,  occlusion  may  result  causing  temporary  deafness.  The 
most  characteristic  symptom  of  erythematous  eczema  of  the  ex- 
ternal auditory  canal,  besides  the  appearance  of  small  flakes,  is  intense 
and  persistent  itching.  It  often  results  from  the  irritation  of  a 
discharge  from  the  ear  and  from  treatment  directed  toward  the  middle 
ear. 

Treatment. — For  acute  vesicular  or  pustular  eczema,  removal  of 
the  crusts  and  the  use  of  calomel  as  an  ointment  in  the  strength 
of  30  gr.  (2  gm.),  to  the  ounce  (32  gm.).  If  chronic,  the  use  of  tar, 
as  already  suggested.  For  chronic  erythematous  eczema  of  the 
external  auditory  canal,  the  following  formula  has  generally  controlled 
this  stubborn  condition : 

I^.      Hydrargyri  flav.  oxid gr.  j  to  iij  o .  065  to  o .  2  gm. 

Morphinae  sulph gr.  j  0.065  gm. 

Vaselini 5ij  8.0  gm. 

M.  S. — Apply  to  the  canal. 

Eczema  Genitalium. — This  is  a  most  distressing  condition.  In 
the  male,  the  scrotum  and  penis  are  involved  alone  or  together, 
the  former  alone  being  the  more  common,  and  is  complicated  with 


ECZEMA  677 

eczema  of  the  inner  side  of  the  thigh  or  thighs.  The  symptoms  are: 
swelHng,  often  edema,  moisture,  crusts,  and  painful  fissures,  followed 
by  extensive  thickening  accompanied  with  intense  itching.  In 
the  female,  the  affection  attacks  the  labia,  and,  rarely,  the  vagina  and 
mons  Veneris,  and  may  extend  to  the  surrounding  parts,  especially 
to  the  perineum.  The  symptoms  of  eczema  of  the  labia  are:  great 
swelling,  edema  redness,  with  great  heat  and  a  free  discharge,  forming 
crusts,  which  are  apt  to  glue  the  apposing  surfaces  together.  If  the 
variety  be  the  erythematous,  in  place  of  a  discharge  with  crusts, 
the  symptoms  named  are  followed  by  slight  scales.  The  itching  is 
most  violent  and  distressing.  Uncleanliness  and  neglect  serve  to  ag- 
gravate the  condition.  Glycosuria  may  be  a  factor  in  its  production. 
Treatment. — The  parts  attacked  should  be  kept  constantly  envel- 
oped in  cloths  wet  with  a  saturated  solution  of  boric  acid  until  the 
more  pronounced  inflammatory  symptoms  subside,  when  the  boric 
acid  may  be  used  as  a  dusting  powder,  completely  enveloping  the 
parts.  Mild  solutions  of  menthol  are  valuable.  Tincture  of  myrrh 
or  witch  hazel,  well  diluted,  are  excellent  applications.  The  following 
is  an  excellent  application  for  eczema  of  the  scrotum: 

I^.     Acidi  borici q.  s.  for  sat.  sol. 

Tinct.  myrrh f  5  ss  1 6 .  o  c.c. 

Tinct.  camphorse fgij  60.0  c.c. 

Hydrarg.  chlor.  cor gr.  iij  0.2  gm. 

Aquae  destil q.  s.  ad  f  5viij  q.  s.  ad  240.0  c.c. 

M.  S. — Apply  several  times  daily. 

An  excellent  formula  for  eczema  of  the  vulva  is : 

I^.     lodoformi 5ss  2  gm. 

Balsami  Peruviani f  5j  4  c.c. 

Petrolat 5j  32  gm. 

M.  S. — Apply  on  soft  cloths. 

Eczema  of  the  genitalia  is  always  obstinate  to  treatment  and  re- 
quires constant  attention  to  both  the  local  and  general  condition  of 
the  patient.  Other  remedies  employed  in  eczema,  elsewhere,  should 
be  given  a  fair  trial. 

Eczema  Ani. — The  anus  may  be  attacked  alone  or  associated  with 
eczema  of  the  perineum  and  genitalia.  The  symptoms  are  redness, 
swelling,  infiltration,  and  thickening,  with  or  without  fluid  exudation. 
Fissures  of  the  anus  are  usually  present,  and  add  to  the  distress  of  the 
patient,  severe  pain  attending  each  stool.     Parasites,  hemorrhoids. 


678  ECZEMA 

and  rectal  discharges,  persistent  itching  and  burning,  worse  after 
retiring,  add  to  the  discomfort  of  the  patient. 

Pruritis  ani  may  be  mistaken  for  eczema  ani.  In  the  former  the 
itching  is  only  associated  with  such  symptoms  of  inflammation  as 
result  from  irritation  of  scratching,  while  in  the  latter  inflammatory 
symptoms  precede  the  itching. 

Treatment. — No  treatment  is  complete  without  some  means  being 
taken  to  ascertain  and  remove  the  underlying  cause.  The  more 
acute  symptoms  are  relieved  by  bathing  the  parts  with  a  solution  of 
boric  acid,  afterward  using  a  weak  application  of  carbolic  acid, 
either  as  a  lotion  or  ointment.  The  late  S.  D.  Gross  recommended 
the  application  of  the  following: 

I^.     Zinci  oxidi 5vj  24.0      gm. 

Hydrargyri  chlor.  corrosiv.   gr.  j  0.065  gi^- 

Glycerini f 5ij  8-0      c.c. 

M.  S. — Apply  thoroughly  to  affected  parts. 

Eczema  Intertrigo. — Parts  of  the  body  that  naturally  come  into 
contact  with  each  other,  as  about  the  joints,  the  inner  surfaces  of  the 
nates,  in  the  groins,  and  beneath  the  mammae,  are  frequently  attacked 
with  erythematous  eczema.  The  symptoms  are  redness,  heat,  and 
a  moist,  macerated  surface,  aggravated  by  movement  of  the  affected 
parts. 

Treatment. — The  application  of  a  solution  of  boric  acid,  or  the  use 
of  dusting  powders,  such  as  zinc  oleate,  starch,  or  calomel,  is  benefi- 
cial. It  is  essential  for  successful  treatment  that  the  opposing  sur- 
faces be  separated  by  means  of  lint  or  gauze. 

Eczema  Mammarum. — The  nipples,  and  more  particularly  those 
of  primiparse,  are  at  times  the  seat  of  a  vesicular  eczema,  with  the 
formation  of  crusts  and  fissures,  and  unless  speedily  relieved,  develop 
eczema  rubrum.  The  pain  on  nursing  becomes  so  severe  that  the 
mother  is  compelled  to  refuse  the  child.  It  must  be  borne  in  mind 
that  eczema  mammarum  also  occurs  in  women  who  are  not  nursing 
and  in  single  women. 

Treatment. — Tilbury  Fox  advises  the  following  plan: 

"i.  Great  cleanliness  and  care  in  washing  away  any  remnants  of 
milk  after  each  time  the  child  is  put  to  the  breast;  and  if  the  nipple 
be  tender  and  excoriated,  use — 

"2.  A  little  lead-water  and  calamine  powder,  as  follows: 


ECZEMA  679 

I^.     Liq.  plumbi f  3jss  6  c.c. 

Pulv,  calaminae  praep 3iss  6  gm. 

Glycerini f3j  4  c.c. 

Adipis 5j  32  gm.        M. 

"3.  I  cover  over  the  nipple  with  a  lead  nipple-shield.  This  ex- 
cludes the  air,  keeps  the  part  from  being  chafed,  and  I  think  the  lead 
does  good  after  the  part  has  become  less  red  and  sore.  I  often  use  a 
little  glycerite  of  tannic  acid,  painted  on  night  and  morning. 

''The  above  application  can  always  be  removed  with  a  little  cold 
cream  and  a  little  warm-water  sponging  before  the  child  goes  to  the 
breast." 

Eczema  Palmarum  et  Plantarum. — The  features  of  the  affection  in 
both  these  regions  are  identical.  The  diagnosis  is  often  obscured  by 
the  thickened  state  of  the  epidermis.  The  symptoms  are  infiltration, 
thickening,  callosity,  moisture  followed  by  dryness,  and  Assuring,  the 
last  named  frequently  becoming  so  deep  and  painful  that  the  patient 
is  unable  to  use  his  hands,  or,  if  on  the  soles,  to  walk.  The  affection 
is  always  chronic,  affecting  either  of  the  parts  alone,  or  all  at  one  and 
the  same  time.     Itching  is  a  constant  and  annoying  symptom. 

The  diagnosis  is  to  be  made  between  eczema  of  these  parts  and 
psoriasis  or  syphilis. 

Treatment. — The  plan  of  Hebra  for  eczema  rubrum  will  usually  be 
successful  for  this  variety.     The  following  formula  is  also  valuable: 

I^.     Hydrargyri  cleat.   5  to   15 

per  cent 5iv  16  gm. 

Olei  cadini f  5ss  2  c.c. 

Cerat.  simplicis 5iv  16  gm. 

M.  S. — Rub  well  into  parts  morning  and  night,  first  macer- 
ating with  hot  water. 

Eczema  Unguium. — The  nails  are  seldom  attacked  alone,  but 
in  connection  with  eczema  manuum.  The  symptoms  are  roughness, 
want  of  polish,  unevenness,  and  a  punctate  or  honeycomb  appearance, 
similar  to  that  seen  in  psoriasis  of  the  nails.  The  nail  becomes 
depressed,  particularly  at  its  root,  thus  interfering  with  its  nutrition, 
resulting  in  loss  of  this  appendage. 

Treatment. — Internally,  arsenic  is  a  valuable  remedy.  Locally, 
the  following : 

I^.     Ung.  picis  liq 5iv  16  gm. 

Hydrargyri  chlor.  mitis .  . . .  5  ss  2  gm. 

Vaselini 5  iv  16  gm. 

M.  S. — Apply  thoroughly. 


68o  ECZEMA    SEBORRHOICUM 

Eczema  Crurum. — Eczema  of  the  legs  is  usually  encountered  in 
poor  persons  past  middle  age.  Varicose  veins  are  nearly  always 
present.  The  treatment  should  be  mild  and  soothing  at  first,  in- 
cluding boric-acid  lotion  or  resorcin  lotion  through  the  day  and  a 
paste  applied  as  a  plaster.  While  the  area  is  discharging  it  should 
not  be  bandaged.  Whenever  possible,  rest  should  be  procured. 
After  the  moist  character  has  disappeared,  the  diseased  area  may  be 
stimulated  by  the  various  means  already  mentioned  and  the  leg 
supported  by  a  bandage,  preferably  one  of  elastic  webbing. 

In  all  cases  of  eczema,  the  use  of  composite  remedies  of  unknown 
proportions  is  dangerous,  as  in  most  cases  the  disease  is  aggravated. 
As  previously  stated,  there  is  no  specific  for  this  affection;  the  appli- 
cations and  dosage  varying  with  different  individuals  and  with  differ- 
ent types  of  the  disease. 

ECZEMA  SEBORRHOICUM 

Seborrhoic  eczema  is  an  inflammatory  disease  beginning  primarily 
on  the  scalp  and  extending  to  the  face,  chest,  and  elsewhere  over 
the  body,  characterized  by  irregular  patches  of  redness,  or  yellowish 
redness  and  scaliness.  It  is  probably  due  to  a  parasite.  The  scales 
are  grayish  or  dirty- white  in  color  and  greasy  to  the  touch.  It 
resembles  seborrhea  but  has  an  additional  inflammatory  element 
absent  in  that  affection. 

The  treatment  consists  in  removing  the  scales  by  means  of  soap 
and  water,  after  which  a  weak  sulphur  ointment  (gr.  xxx  to  the  ounce) 
or  resorcin  lotion  (gr.  viij  to  the  ounce)  should  be  applied.  The 
scalp  should  receive  careful  attention. 

IMPETIGO  CONTAGIOSA 

Definition. — An  acute  contagious  inflammatory  disease  char- 
acterized by  the  development  of  one  or  more  discrete  superficial 
vesicles  or  blebs,  of  various  size  and  shape,  the  contents  of  which  soon 
become  purulent,  producing  yellowish  or  brownish  crusts. 

Causes. — The  affection  is  observed  most  often  in  poor  and  un- 
clean children.  It  is  contagious  and  autoinoculable.  Occasionally 
it  follows  vaccination.  When  occurring  in  the  scalp,  it  may  nearly 
always  be  traced  to  pediculosis  capitis.  Institutions,  laundries, 
barber  shops,  etc.,  often  aid  in  producing  epidemics.  The  exciting 
cause  is  inoculation  with  the  ordinary  pus  miroorganisms. 


ECTHYMA  68 1 

Pathology. — Among  the  microorganisms  capable  of  producing 
this  affection  may  be  mentioned  the  staphylococcus  aureus,  staphy- 
lococcus albus,  streptococcus,  and  occasionally  the  tricophyton  fun- 
gus. The  bleb  is  formed  between  the  rete  mucosum  and  the  horny 
layer  of  the  epidermis,  the  roof-wall  being  afforded  by  the  latter. 
A  mild  inflammatory  reaction  surrounds  the  lesion  having  its  seat 
in  the  upper  layer  of  the  corium.  The  bleb  contains  a  whitish  yellow 
fluid,  pus  corpuscles,  blood  corpuscles,  epithelial  cells,  cellular 
detritus,  and  microdrganisms. 

Symptoms. — The  eruption  appears  with  greatest  frequency  on  the 
face  and  hands  and  often  follows  some  very  trivial  injury,  as  a  scratch. 
As  the  lesions  appear,  their  contents  are  clear,  but  within  a  day  or 
so  the  vesicle  or  bleb  character  is  lost  and  they  assume  all  the  features 
of  pustules.  The  pustules  rapidly  dry,  forming  crusts  which  have 
a  ''stuck  on"  appearance.  After  several  days  these  drop  off  leaving 
a  slightly  red  area  beneath.  Usually,  there  are  present  at  the  same 
time  several  lesions  in  various  stages  of  development.  The  vesico- 
pustules  may  coalesce  forming  several  large  blebs  or  they  may  arrange 
themselves  in  half -circles.  Itching  is  very  slight  or  absent.  Neg- 
lect or  improper  treatment  may  cause  the  development  of  an  eczema 
on  an  impetiginous  area.  The  duration  of  the  disease  is  in  most 
instances  from  ten  days  to  two  weeks. 

Treatment. — The  crusts  should  be  removed  by  means  of  some 
nonirritating  soap  and  water,  after  which  the  following  may  be 
applied. 

I^.     Hydrarg.  ammoniat gr.  v  0.3  gm. 

Hydrarg.  oxid.  rub gr.  v.  0.3  gm. 

Petrolat §j  32  .0  gm. 

M.  S. — Apply  locally  twice  daily  (Stelwagon). 

Other  mild  antiseptics  such  as  boric  acid,  sulphur,  etc.,  may  be 
employed,  care  being  taken  to  reduce  the  strength  sufficiently  to 
avoid  irritation. 

ECTHYMA 

Definition. — An  affection  of  the  skin,  characterized  by  the  forma- 
tion of  one  or  more  large,  isolated,  flat  pustules,  situated  upon  an 
inflamed  base. 

Causes. — It  is  most  common  among  those  who  live  in  squalor 
and  poverty,  in  unclean  adults,  and  in  delicate,  and  poorly  nourished 


682  DERMATITIS   HERPETIFORMIS 

children.  Improper  and  insufficient  diet,  want  of  ventilation,  ex- 
cessive work,  and  uncleanliness  are  all  prominent  causes.  It  should 
be  remembered  that  ecthymiform  lesions  also  occur  at  times  in  the 
course  of  pediculosis,  scabies,  and  syphilis. 

Pathology. — The  lesion  is  a  typical  pustular  process,  severe  but 
superficial,  and  not  extending  beyond  the  papillary  layer  of  the  cor- 
ium.  The  pustule  is  situated  upon  a  firm  and  highly  inflamed  base ; 
the  number  varies  from  one  to  a  dozen  or  more.  With  the  disappear- 
ance of  the  lesions  pigmentation  and  scarring  may  follow.  The  ex- 
citing cause  of  the  affection  is  the  presence  of  pus-producing  micro- 
organisms in  the  debilitated  skin. 

Symptoms. — The  disease  is  characterized  by  the  development  of 
one  or  more  round  or  oval,  flat  pustules,  about  the  size  of  a  pea  or 
bean,  attended  with  moderate  heat,  burning,  and  pain,  and  if  the 
number  be  large,  slight  febrile  reaction.  The  pustules  are  first 
yellowish  in  color,  surrounded  by  a  firm  and  sensitive  bright  red 
areola,  the  pustule  afterward  becoming  reddish  from  the  admixture 
of  blood,  soon  drying  into  flat  crusts  of  a  brownish  color.  The  dura- 
tion of  each  pustule  is  between  two  and  three  weeks,  new  ones  forming 
until  the  cause  is  removed.  The  most  prominent  sites  are  the  thighs, 
legs,  shoulders,  and  back. 

Diagnosis. — Ecthyma  may  be  distinguished  from  other  pustular 
affections  by  its  predilection  for  the  legs  of  unclean  persons,  usually 
adults,  and  by  the  presence  of  discrete,  flat,  deep-seated  pustules 
with  broad  inflammatory  areolas. 

Treatment. — Without  treatment  the  affection  may  persist  indefi- 
nitely but  under  proper  care  the  response  is  prompt.  A  bath  with  a 
change  of  clothing  should  begin  the  treatment.  A  search  should  be 
made  for  animal  parasites  and  if  found,  appropiate  measures  should 
be  instituted.  Nutritious  food  and  tonics  should  be  given.  Locally, 
cleanliness  and  the  following  application  are  of  great  value : 

I^.     Acid  carbol gr.  v  o  •  33  gm- 

Hydrarg.  ammoniat gr.  xxx  2 .  o    gm. 

Petrolat §  j  32 .  o    gm. 

M.  S. — Apply  locally  twice  daily. 

DERMATITIS  HERPETIFORMIS 

S3mon3mis. — Duhring's  disease;  hydroa;  herpes  gestationis. 
Definition. — An    inflammatory,    superficially    seated,    multiform, 


PEMPHIGUS  683 

herpetiform  disease,  characterized  mainly  by  erythematous,  vesicu- 
lar, pustular,  and  bullous  lesions,  occurring  usually  in  varied  com- 
binations, accompanied  by  burning  and  itching,  pursuing  usually  a 
chronic  course,  with  a  tendency  to  relapse  and  recur  (Duhring).  The 
affection  occurs  most  often  in  middle  life  and  arises  from  a  number 
of  causes,  chief  of  which  are  disturbances  of  the  nervous  system. 

Treatment. — The  cause  should  be  ascertained  and  removed.  Ton- 
ics, especially  arsenic,  act  most  favorably  on  the  disease.  Rest, 
nutritious  diet,  and  attention  to  personal  hygiene  are  important. 
Phenacetin,  acetanilide,  belladonna,  and  cannabis  indica  will  often 
relieve  the  symptoms  when  administered  internally.  Locally,  appli- 
cations containing  carbolic  acid,  resorcin,  tar,  sulphur,  and  ichthyol 
are  of  value.  Duhring  recommends  a  strong  sulphur  ointment  in  the 
vesicular  and  pustular  types. 

PEMPHIGUS 

Definition. — An  inflammatory  disease  of  the  skin,  either  acute  or 
chronic,  characterized  by  the  development  of  a  succession  of  rounded, 
irregularly-shaped  blebs  or  bullae,  varying  in  size  from  a  pea  to  an  egg. 

Causes. — Obscure.  Nervous  prostration,  general  debility,  hered- 
ity, female  sex,  disorders  of  menstruation,  pregnancy,  etc.,  are 
important  indirect  etiological  factors. 

Pathology. — The  affection  is  considered  to  be  a  trophoneurosis. 
The  blebs  are  situated  in  the  epidermis  and  probably  arise  from  a 
sudden  effusion  from  the  vessels  of  the  corium  as  the  result  of  dilata- 
tion. The  contents  of  the  blebs  or  bullae  are  yellowish  or  colorless 
serum,  of  a  neutral  or  alkaline  reaction;  the  older  the  fluid,  the  more 
alkaline  it  becomes.  In  the  late  stages  of  a  bleb  the  fluid  becomes 
puriform.  In  rare  instances  blood  is  contained  in  the  bleb  {pemphi- 
gus hcBmorrhagicus) .  The  papillary  vessels  are  dilated  and  the  pap- 
illae, corium,  and  subcutaneous  tissue  are  edematous  and  infiltrated 
with  leukocytes. 

Symptoms. — There  are  two  varieties :  pemphigus  vulgaris ;  pemphi- 
gus foliaceus. 

Pemphigus  vulgaris  may  be  acute  or  chronic  and  may  or  may  not 
be  accompanied  by  febrile  reaction.  It  is  manifested  by  the  succes- 
sive development  of  blebs  varying  in  size  from  that  of  a  pea  to  an  egg, 
of  a  round  or  oval  shape  containing  a  colorless  fluid,  the  color  becom- 
ing yellowish  or  puriform  as  they  grow  older.     They  arise  abruptly 


684  ■  PEMPHIGUS 

from  the  sound  skin  with  a  definite  Une  of  demarcation,  unattended 
by  symptoms  of  inflammation.  A  characteristic  feature  of  the  erup- 
tion is  the  successive  appearance  of  the  lesions;  one  crop  no  sooner 
disappears  than  another  forms,  each  crop  running  its  course  in  from 
three  to  six  or  ten  days.  The  limbs,  face  and  trunk  are  the  regions 
most  often  affected  but  the  condition  may  also  involve  the  mucous 
membranes.  Itching  and  burning  of  a  mild  degree  are  present; 
occasionally  they  are  very  severe  {pemphigus  pruriginosus). 

Pemphigus  malignus  is  characterized  by  the  great  size  and  number 
of  the  blebs,  which  coalesce,  rupture,  and  are  succeeded  by  excoriated 
surfaces,  which  occasionally  take  on  ulcerative  action,  seriously 
impairing  the  patient's  health. 

Pemphigus  foliaceus  differs  from  pemphigus  vulgaris  in  that  the 
blebs,  instead  of  being  distended  or  tense,  are  flaccid  and  only  par- 
tially filled  with  fluid,  and  they  rupture  before  arriving  at  their  state  of 
full  development.  This  variety  also  appears  and  disappears  in  crops. 
After  rupture  the  fluid  immediately  dries  into  thin,  whitish  flakes, 
which  are  detached  in  quantity,  leaving  a  red,  excoriated  surface — 
the  rete  and  corium.  If  the  affection  has  continued  for  sometime, 
the  skin  presents  the  appearance  of  a  superficial  scald.  The  course  of 
this  variety  is  essentially  chronic.  All  portions  of  the  body  surface 
are  hable  to  the  lesion,  as  is  also  the  mucous  membrane  of  the  mouth 
and  vagina.     It  is  most  common,  however,  upon  the  limbs. 

Pemphigus  vegetans  is  a  rare  variety  of  the  disease  in  which  wart- 
like vegetations  develop  upon  the  sites  of  the  ruptured  blebs. 

Diagnosis. — The  disease  is  rare,  and  the  presence  of  blebs  in  any 
given  case  should  direct  the  attention  to  pemphigus  only  after  bullous 
erythema  multiforme,  impetigo  contagiosa,  bullous  syphiloderm,  and 
bullous  eruptions  of  artificial  production  have  been  excluded.  The 
characteristics  of  pemphigus  are  its  chronicity,  and  the  appearance  in 
crops  of  large,  tense,  abruptly  elevated  non-inflammatory  blebs. 

Prognosis. — The  outlook  is  uncertain.  Most  cases  pursue  a 
very  chronic  course  ultimately  ending  in  death  from  some  inter- 
current disease.  Mild  attacks  are  less  liable  to  persist  and  often  end 
in  recovery.  Constitutional  disturbances,  extensive  involvement 
of  the  skin,  and  the  presence  of  flaccid  or  hemorrhagic  blebs  are  un- 
favorable signs. 

Treatment. — The  general  health  should  be  restored  and  maintained 
by  rest,  nutritious  food,  and  the  administration  of  tonics  especially 
arsenic  and  quinine.     Locally,  the  blebs  should  be  punctured  as 


HERPES    SIMPLEX  685 

soon  as  formed  and  dusting  powders  such  as  boric  acid,  zinc  oxide, 
or  starch  should  be  appUed  locally.  Sedative  lotions  are  also  valuable. 
Hebra  advises  the  continuous  bath. 

POMPHOLYX 

Synon5ans. — Dysidrosis ;  cheiro-pompholyx. 

Definition. — An  acute  inflammatory  disease  of  the  skin,  affecting 
especially  the  hands  and  feet,  characterized  by  the  appearance 
of  vesicular,  vesicobuUous,  and  bullous  lesions,  attended  by  burning, 
tingling,  or  itching. 

Causes. — It  occurs  in  adults  of  both  sexes,  and  is  believed  to 
depend  upon  some  general  disturbance  of  the  nervous  system. 
Mental  overwork  and  lowered  nerve-tone  are  ascribed  as  causes.  The 
disease  is  considered  to  be  a  vasomotor  neurosis. 

Symptoms. — The  lesions  are  distributed  symmetrically,  and 
occur  as  deep-seated  tense  vesicles  usually  on  the  lateral  and  palmar 
aspects  of  the  hands,  fingers,  feet,  and  toes,  accompanied  by  itching 
and  burning.  They  may  coalesce,  but  more  frequently  they  remain 
discrete,  showing  no  tendency  to  rupture.  The  contents  are  absorbed 
and  desquamation  follows.  The  duration  of  the  attack  is  from  several 
days  to  a  few  weeks.     Recurrence  is  common. 

Diagnosis. — The  affection  may  resemble  vesicular  eczema  and 
dermatitis  venenata.  The  distinctive  features  of  pompholyx  are 
the  location,  the  tense,  deep-seated  character  of  the  vesicles  which 
do  not  tend  to  rupture,  the  subjective  symptoms,  the  absence  of 
acute  inflammation,  and  the  tendency  to  recur. 

Prognosis. — The  acute  attacks  seldom  last  more  than  one  or  two 
weeks  and  the  course  is  seldom  influenced  by  treatment.  The  ten- 
dency to  relapse  has  already  been  mentioned. 

Treatment. — Recurrence  may  be  prevented  to  a  great  extent  by 
the  employment  of  measures  calculated  to  improve  the  general 
health.  Locally,  pastes,  ointments,  or  lotions  containing  antipruritic 
drugs  often  allay  the  subjective  symptoms. 

HERPES  SIMPLEX 

Synonyms. — Fever  blisters;  ''cold  sore." 

Definition. — An  acute  inflammation  of  the  skin,  characterized 
by  the  development  of  one  or  more  groups  of  vesicles,  filled  with  a 


686  HERPES   SIMPLEX 

clear  serum,  occurring  for  the  most  part  about  the  face  {herpes  facialis 
and  genitalia  {herpes  pro  genitalis). 

Causes. — Herpes  facialis  occurs  during  the  course  of  febrile  and 
nervous  disorders  and  is  often  associated  with  gastrointestinal 
disorders.  Herpes  progenitalis  usually  arises  from  uncleanliness  and 
friction. 

Pathology. — The  affection  is  neurotic  in  origin,  and  by  some 
observers  is  believed  to  be  due  to  a  toxic  neuritis  of  a  cutaneous  nerve. 

Symptoms. — The  appearance  of  the  vesicles  is  usually  preceded 
by  a  feeling  of  heat  in  the  region,  together  with  slight  tumefaction 
or  swelling.  Rarely  the  herpetic  attack  is  attended  with  malaise 
and  pyrexia.  The  eruption  usually  appears  in  the  form  of  a  small 
cluster  of  pin-head  to  split-pea  sized  vesicles,  containing  a  clear  fluid, 
becoming  cloudy,  afterward  puriform  and  drying  in  small  yellowish 
or  brownish  crusts;  they  are  few  in  number,  and  may  coalesce.  They 
disappear  without  leaving  a  scar. 

Herpes  facialis  occurs  upon  any  portion  of  the  face,  but  most 
frequently  about  the  lips — herpes  labialis.  The  alae  of  the  nose, 
auricles,  and  the  mucous  membranes  of  the  mouth  and  tongue 
are  frequent  locations,  in  the  latter  appearing  as  excoriated  patches 
from  rupture  of  the  vesicles. 

Herpes  progenitalis;  in  the  male  the  chief  site  is  the  prepuce  {herpes 
prceputialis) .  In  the  female  it  is  comparatively  rare;  but  when 
occurring  it  appears  upon  the  labia  majora  and  minora  and  the 
skin  about  the  vulva.  This  variety  is  preceded  by  burning,  itching, 
or  neuralgic  pains,  and  is  accompanied  by  redness,  congestion,  and 
more  or  less  edema.  The  importance  of  this  condition  resides 
in  the  fact  that  not  only  may  it  be  readily  mistaken  for  some  venereal 
disease  but  it  may  also  afford  a  site  for  inoculation  for  some  more 
serious  affection. 

Herpes  gestationis;  a  rare  affection  of  the  skin  occurring  during 
pregnancy,  consisting  of  erythema,  papules,  vesicles,  and  bullae, 
attended  by  intense  burning  and  itching.  It  may  appear  at  any 
time  of  pregnancy  up  to  the  seventh  month,  and  continues  until 
after  delivery.     It  is  a  variety  of   dermatitis   herpetiformis  {q_.v.). 

For  herpes  zoster  see  page  604. 

Treatment. — Ordinary  herpes  of  the  face  seldom  requires  treat- 
ment, the  lesions  drying  and  falling  off  usually  within  a  week  or  ten 
days.     The  application  of  dusting  powders,  cold  cream,  or  boric 


LICHEN   PLANUS  687 

acid   solution   often   aids   in   lessening  the  itching  and  preventing 
infection. 

In  herpes  progenitalis,  cleanliness  is  of  first  importance.  The 
lesions  should  be  carefully  washed  with  boric-acid  solution  and  then 
dusted  with  calomel,  aristol,  or  similar  powders.  The  parts  may- 
be rendered  less  sensitive  in  frequently  recurring  cases  by  astringent 
lotions  containing  tannic  acid  or  zinc  sulphate.  Circumcision  will 
be  necessary  when  an  unusually  long  prepuce  is  the  cause  of  the 
condition.  In  recurring  cases  of  herpes  of  the  vulva,  arsenic,  inter- 
nally, is  of  benefit. 

LICHEN  PLANUS 

Lichen  planus  is  a  chronic  inflammatory  disease  of  the  skin 
characterized  by  small,  flat,  angular,  umbilicated,  glazed,  reddish 
papules,  accompanied  by  intense  itching.  The  eruption  may  appear 
suddenly  or  gradually  and  usually  appears  on  the  extremities.  The 
lesions  vary  in  size  from  a  pin-head  to  a  pea  and  tend  to  occur  in 
patches  which  often  assume  a  linear  form.  The  papules  are  flat, 
angular,  glazed,  slightly  umbilicated  and  of  a  reddish  or  violaceous 
color.  As  the  affection  progresses  scales  form  on  the  lesions.  Itch- 
ing is  marked.  After  the  eruption  subsides,  the  sites  of  the  lesions 
remain  pigmented  for  an  indefinite  period. 

Causes. — Unknown.  Disturbances  of  the  nervous  system,  such  as 
result  from  prolonged  mental  strain,  overwork,  etc.,  are  prominent 
factors  in  the  etiology.  The  condition  is  observed  with  greatest 
frequency  in  middle-aged  individuals  in  whom  there  is  marked  dis- 
turbance of  the,  general  health. 

Pathology. — The  lesions  are  induced  by  some  neurotic  disturbance 
as  yet  not  well  understood.  They  are  situated  in  the  upper  part  of 
the  corium  usually  surrounding  the  sweat-ducts.  The  earliest  step  in 
their  production  is  probably  a  neuroparalytic  hyperemia,  after  which 
there  is  a  circumscribed  round-cell  infiltration  of  the  corium  with  en- 
largement of  the  papillae  and  proliferation  of  the  cells  of  the  rete. 

Diagnosis. — The  distinctive  features  of  lichen  planus  are  its  chron- 
icity  and  the  shape,  size,  and  color  of  the  lesions. 

Prognosis. — The  course  is  essentially  chronic,  but  proper  treat- 
ment often  causes  disappearance  of  the  eruption. 

Treatment. — Internally;  remedies  such  as  arsenic,  iron,  quinine, 
strychnine,  and  cod-liver  oil  should  be  administered.     Rest  is  of 


688  •  PRURIGO 

value.  The  diet  should  be  regulated  and  the  personal  hygiene  should 
receive  attention. 

Locally,  lotions  and  ointments  containing  antipruritics  should  be 
employed.  Tar,  mercury,  salicylic  acid,  menthol,  and  carbolic  acid 
are  useful  in  this  connection. 

Lichen  ruber  acuminatus  is  characterized  by  the  appearance  of  dis- 
crete millet-sized,  acuminate,  scaly  papules.  The  trunk  is  the  most 
common  situation.  The  lesions  are  scattered  and  show  no  tendency 
to  grouping.  They  are  localized  in  the  hair-follicles.  The  hair- 
sheaths  are  changed  to  funnel-shaped  formations,  with  the  wide  end 
external  and  the  narrow  end  pointed  toward  the  bulb,  and  the  papillae 
and  contained  blood-vessels  are  enlarged.  Itching  is  not  marked. 
The  affection  is  very  chronic  and  is  attended  by  constitutional  distur- 
bances. The  treatment  is  similar  to  that  of  lichen  planus  but  is  seldom 
of  much  benefit. 

Lichen  Scrofulosus. — A  chronic  disease  of  the  skin,  characterized 
by  the  formation  of  millet-seed  sized,  rounded  or  flattened,  pale  red 
or  salmon  colored,  more  or  less  grouped,  scaly  papules.  They  are 
observed  most  frequently  on  the  trunk  in  scrofulous  individuals  and 
are  unaccompanied  by  itching.  The  treatment  consists  largely  in  the 
internal  use  of  cod-liver  oil,  iron,  quinine,  and  strychnine.  The  cod- 
liver  oil  may  also  be  employed  locally. 

PRURIGO 

Prurigo  is  a  rare  chronic  inflammatory  disease,  occurring  first  in 
early  childhood  and  lasting  indefinitely,  characterized  by  pin-head 
to  lentil-seed  sized,  pale,  red  papules  appearing  usually  on  the  exten- 
sor surfaces  of  the  extremities  and  accompanied  by  intense  itching. 
The  cause  is  unknown.  The  affection  occurs  most  often  among  the 
poor.     The  outlook  is  unfavorable. 

Treatment. — Every  effort  should  be  made  to  improve  the  general 
health  and  to  this  end  the  diet  and  hygiene  should  receive  attention. 
Cod-liver  oil,  iron,  manganese,  hypophosphites,  etc.,  should  be  given. 
Locally,  bathing  in  plain  water  or  medicated  solutions,  betanaphthol 
ointment  (2  per  cent,  in  children,  5  per  cent,  in  adults),  sulphur 
ointment  (5  j  to  the  ounce),  and  tar  preparations  are  of  great  value. 

ACNE 

Synon5rm. — Acne  vulgaris. 

Definition. — An  inflammation,  usually  chronic,  of  the  sebaceous 


ACNE  689 

glands,  characterized  by  the  development  of  papules,  tubercles,  or 
pustules,  or  by  a  combination  of  such  lesions,  usually  in  various  stages 
of  formation,  occurring  for  the  most  part  upon  the  face. 

Varieties. — Acne  papulosa;  acne  pustulosa;  acne  artificialis. 

Causes. — The  exciting  cause  is  not  well  understood;  by  many 
observers  it  is  believed  to  be  a  microorganism.  As  predisposing 
causes  may  be  mentioned  puberty,  digestive  disturbances,  consti- 
pation, menstrual  irregularities,  anemia,  chlorosis,  circulatory  dis- 
turbances, sedentary  life,  general  debility,  and  lack  of  muscular  tone. 
The  presence  of  dust  and  oil  on  the  face,  uncleanliness,  contact  with 
tar,  and  the  internal  administration  of  the  bromides  and  iodides  in 
excess  are  also  etiological  factors.  Acne  may  exist  alone  or  be  asso- 
ciated with  comedo  or  seborrhea. 

Pathology. — An  inflammation  of  the  sebaceous  gland  structure  and 
surrounding  tissues.  There  first  occurs  retention  of  the  sebaceous 
secretion,  which  is  soon  followed  by  hyperemia  and  exudation  about 
the  glands  and  in  the  gland- wall  {acne  papulosa),  and  infiltration  of 
the  connective  tissue  {acne  tuhercula),  followed  by  suppuration  {acne 
pustulosa).  If  the  inflammatory  action  be  severe,  destruction  of  the 
gland  with  a  resulting  cicatrix  occurs. 

SjTnptoms. — Acne  papulosa  or  acne  punctata.  This  variety  is  the 
earliest  stage  of  the  inflammatory  action,  and  is  of  short  duration, 
soon  followed  by  the  development  of  pus.  It  is  characterized  by  the 
occurrence  of  pin-head  to  pea-sized,  fiat,  more  or  less  pointed  papules, 
situated  about  the  sebaceous  follicles,  light  in  color,  with  a  minute 
central  black  point,  the  opening  of  the  sebaceous  duct  {acne  punctata) . 
Pustules  are  not  infrequently  observed  scattered  among  the  papules. 
The  lesion  is  unaccompanied  with  either  local  or  constitutional 
symptoms.  While  the  forehead  is  the  most  frequent  seat  for  this 
variety,  they  sometimes  are  seen  elsewhere. 

Acne  Pustulosa. — This  is  the  fully  developed  affection.  It  is  seen 
upon  the  face,  neck,  shoulders,  and  back  as  rounded  or  acuminated 
pustules,  which  vary  in  size  from  that  of  a  pin-head  to  a  pea,  seated 
upon  an  infiltrated,  reddish  base  of  superficial  or  deep  inflammatory 
product  {acne  indurata).  Scattered  among  the  pustules  may  be  seen 
numerous  papules.  There  are  no  constitutional  symptoms,  nor  is 
pain  present  unless  the  pustule  be  handled. 

Acne  cachecticorum  is  that  variety  observed  on  the  trunk  and  ex- 
tremities of  cachectic  individuals.     The  lesions  are  large  and  indolent. 

Acne  atrophica  is  characterized  by  the  formation  of  small  atrophic 
44 


690  ACNE 

scars  on  the  disappearance  of  the  lesions,  while  in  acne  hypertrophica, 
the  scar-tissue  is  hypertrophic. 

Acne  artificialis  is  rather  a  clinical  variety,  the  result,  usually, 
of  large  doses  of  the  bromides  or  iodides,  the  lesion  being  identical 
with  that  of  acne  pustulosa. 

Diagnosis. — The  characteristics  of  the  disease  are  the  course, 
location,  and  lesions  situated  at  the  sites  of  the  sebaceous  glands. 

Prognosis. — The  affection  is  essentially  chronic,  lasting  for  a 
number  of  years.  With  persistent  treatment  recovery  is  rather 
common. 

Treatment. — Before  prescribing  for  any  case  of  the  disease,  it 
should  be  carefully  studied  as  to  its  etiology,  since  this  bears  directly 
upon  the  treatment.  In  most  instances,  the  digestive  tract  is  the  sub- 
ject of  various  disturbances  and  internal  medication  is  consequently 
indicated.  The  character  of  the  food  should  be  regulated,  being 
careful  to  eliminate  all  substances  known  to  be  difficult  of  digestion 
in  the  particular  case  under  observation,  and  especially  pastries, 
gravies,  cheese,  fried  foods,  pork,  etc.,  from  the  diet.  Alcoholic 
beverages  should  be  interdicted  and  tea  and  coffee  allowed  in  very 
moderate  quantities.  Constipation  is  common  and  requires  for  its 
relief  moderate  exercise,  abdominal  massage,  and  laxatives  in  addition 
to  regulation  of  the  diet.  Among  the  laxatives  of  value  in  this 
connection  may  be  mentioned  the  compound  rhubarb  pill,  the  aloin, 
strychnine  and  belladonna  pill,  calomel,  blue  mass,  cascara  sagrada, 
and  the  salines.  The  saline  waters  such  as  Hunyadi  Janos,  Saratoga 
and  Friedrichshall  are  very  beneficial.  The  administration  of  so- 
dium hypophosphite,  gr.  x  (0.6  gm.),  in  solution  three  times  daily 
after  meals  is  also  of  value. 

Stel wagon  employs  the  following  combination: 

I^.     Sodii  benzoat 5ss  to  ij      2  to    8  gm. 

Tr.  nucis  vomicae f  5ij  8  c.c. 

Fluidextract.  cascarae f  5ij  to  iv      8  to  16  c.c. 

Tr.  cardamom,  comp. 

q.  s.  ad  f  §iij  90  c.c. 

M.  S. — Teaspoonful  three  times  daily  in  water  after  meals. 

The  following  mixture  known  as  "mistura  ferri  acida"  is  exten- 
sively used  with  success  in  cases  complicated  with  constipation 
and  anemia: 


ACNE  691 

.  I^.     Magnesii  sulphat §  j  32  .0  gm. 

Ferri  sulphat gr.  iv  to  viij    0.25  to  0.5  gm. 

Acid  sulphuric,  dilut f  5j  to  ij  4.0    to  0.8  c.c. 

Aq.  menth.  pip.  q.  s.  ad.  .  .    f  Biv  120.0  c.c. 

M.  S. — Tablespoonful  in  water  half  an  hour  before  breakfast. 

In  cases  in  which  chlorosis  or  anemia  exists,  tonics  such  as  iron, 
arsenic,  and  manganese  should  be  employed.  The  citrate  of  iron 
and  quinine  in  combination  with  glycerin  is  an  excellent  preparation 
for  these  cases.  In  cachectic  or  scrofulous  individuals  cod-liver  oil, 
syrup  of  the  iodide  of  iron,  syrup  of  the  hypophosphites,  and  similar 
remedies  should  be  administered.  The  bichloride  of  mercury,  gr. 
Hoo  to  }io  (0.00065  to  o.ooii  gm.),  three  times  daily,  is  of  great 
value  as  a  tonic  in  many  cases.  In  pustular  cases,  calcium  sulphide, 
gr.  J^o  to  }i  (0.0065  to  0.032  gm.),  three  times  daily,  is  reputed 
to  be  of  benefit.  Change  of  occupation  frequently  aids  the  treat- 
ment materially.  Uterine  disorders  should  always  receive  attention, 
as  they  often  influence  the  condition  considerably.  Other  genital 
conditions  acting  reflexly  should  not  be  neglected.  In  young 
adult  males,  the  passage  of  la  fair-sized  steel  sound  has  been 
advocated. 

Local  Treatment. — The  objects  of  the  local  treatment  are  to  stimu- 
late the  sebaceous  glands  to  healthy  activity  and  to  remove  existing 
lesions.  A  form  of  treatment  that  has  been  followed  by  success 
in  many  cases  consists  in  first  washing  the  face  every  night  with  very 
hot  water;  after  the  face  has  partly  dried  precipitated  sulphur  is 
dusted  on  with  a  powder  puff-ball,  and  removed  in  the  morning  by 
means  of  hot  water  and  the  face  lightly  mopped  dry. 

Hyde  recommends  evacuating  the  contents  of  the  lesions  by 
means  of  a  needle,  rather  encouraging  slight  bleeding,  after  which 
the  parts  are  to  be  bathed  with  hot  water  and  while  the  parts  are 
still  wet  thoroughly  scrubbed  with  green  soap,  cleansed  with  water, 
dried,  and  anointed  with  sulphur  ointment.  This  treatment  is  very 
stimulating  and  is  applicable  only  to  deep-seated  indolent  lesions. 
Sometimes  the  affected  areas  are  decidedly  irritated  when  first  seen 
or  become  so  from  treatment.  Under  such  circumstances,  a  saturated 
solution  of  boric  acid  in  alcohol  or  water,  or  calamine  lotion,  should 
be  used. 

Usually,  when  the  lesions  are  seated  very  superficially  the  following 
"lotio  alba"  will  be  of  benefit: 


692  "  ACNE 

I^.     Zinc,  sulphat, 

Potassium  sulphid aa  gr.  xxx  to  Ix     2  to  4  gm. 

Aquae  rosae f  Biv  120  c.c. 

M.  S, — Apply  locally  at  night,  washing  off  the  sediment  with 
water  in  the  morning. 

In  the  preparation  of  this  solution,  each  ingredient  should  be 
dissolved  separately  and  then  mixed.  When  completed  there 
should  be  a  white  precipitate.  The  addition  of  glycerin  (TTlx  to  the 
ounce)  will  cause  the  sediment  to  be  held  in  suspension  and  often 
aids  in  the  efficiency  of  the  application.  Other  preparations  of 
sulphur,  such  as  sulphur  ointment  and  paste  (5j  to  the  ounce),  and 
Kummerf eld's  solution  are  also  of  value. 

I^.     Sulph.  prsecip 5iv  15.5  gm. 

Pulv.  camphoras gr.  x  0.6  gm. 

Pulv.  tragacanth gr.  xx  1.2  gm. 

Aquae  rosae, 

Liq.  calcis aa  f  § ij  aa     60 .  o  c.c. 

M.    S. — Kummerfeld's    solution.     Apply    locally    night    and 
morning. 

Duhring  reconimends  the  use  of  the  following,  after  washing  the 
parts  with  hot  water: 

I^.     Sulphuris  praecip 5  J  4  •  o  gm- 

Glycerini f 5ss  2.0  c.c. 

Adipis  benzoat g-j  32 .0  gm. 

01.  rosae TTliij  0.2  c.c. 

M.  Ft.  unguentum. 

S. — To  be  thoroughly  rubbed  into  the  skin  at  night. 

The  following  is  employed  extensively  in  sluggish  cases : 

I^.     Sulph.  praecip 5 J  4  gm. 

.^Etheris.* f3iv  16  c.c. 

Alcohol q.  s.  ad  f  5iv  120  c.c. 

M.  S. — Apply  locally  twice  daily. 

Resorcin  is  often  used  in  the  form  of  an  ointment  ( 5  j  to  the  ounce) . 
Among  other  local  remedies  may  be  mentioned  ichthyol,  mercurial 
preparations,  betanaphthol,  and  salicylic  acid.  Incision,  expression, 
faradism,  massage,  and  the  a;-ray  are  also  beneficial  in  selected  cases. 

Bartholow  used  the  following  method  in  cases  of  indurated  acne 
with  success:     The  sebaceous  matter  was  first  dissolved  out  with — 


ACNE    ROSACEA  693 

I^.     Liquor  potassae f  3j  4  c.c. 

Aquae  destil f Bj  30  c.c. 

M.  S. — Apply  only  to  the  acne  lesions,  after  which  the  fol- 
lowing ointment  should  be  used: 

I^.     Plumbi  nitrat gr.  xv  I  gm. 

Petrolat §  j  32  gm. 

M.  S. — Apply  locally  twice  daily. 

Vaccine  therapy  has  been  recommended,  but  it  is  often  disappoint- 
ing; it  may  be  tried  in  obstinate  cases. 

ACNE  ROSACEA 

Synonym. — Rosacea. 

Definition. — A  chronic  hyperemia  or  inflammatory  affection 
of  the  nose  and  cheeks,  characterized  by  redness,  hypertrophy 
of  the  skin,  and  dilatation  and  enlargement  of  the  blood-vessels 
supplying  the  part,  with  the  development  of  more  or  less  acne. 

Causes. — The  etiology  is  often  obscure.  Gastrointestinal  disor- 
ders, anemia,  exposure  to  heat  and  cold,  uterine  disease,  puberty, 
menopause,  general  debility,  seborrhea,  nasal  disease,  and  the  ex- 
cessive indulgence  in  tea,  coffee,  and  alcohol  are  the  most  common 
causes.  Both  sexes  may  be  attacked.  The  affection  usually  occurs 
in  middle  life. 

Pathology. — There  first  occurs  blood  stasis  in  the  vessels  of  the 
part,  producing  the  undue  redness.  As  a  result  of  the  stasis,  sooner 
or  later  the  capillaries  are  dilated  and  hypertrophied,  and  following 
the  interrupted  circulation,  inflammation  of  the  sebaceous  glands 
(acne)  occurs,  with  the  development  of  papules  and  pustules. 
This  constitutes  the  typical  acne  rosacea.  The  affection  may  pro- 
ceed no  further,  remaining  at  this  point  for  years,  or,  rarely,  the 
pathology  of  this  stage  is  exaggerated,  the  involved  tissues  all  hyper- 
trophying,  and  the  connective  tissue  undergoing  a  true  hyperplasia, 
causing  increased  size  and  abnormal  shape  of  the  nose. 

Symptoms. — The  onset  of  the  affection  is  slow  and  insidious, 
characterized  at  first  by  more  or  less  diffused  redness  of  the  part, 
the  color  being  aggravated  by  contact  with  water  or  cold  air.  If 
the  nose  be  the  part  attacked,  it  is  usually  greasy  (seborrheic) 
and  is  apt  to  be  cool  or  even  cold.  This  condition  may  remain  for 
years,  but  sooner  or  later  the  evidence  of  dilatation  and  hypertrophy 
of  the  capillaries  is  apparent  by  the  more  decided  and  permanent 


694  ACNE   ROSACEA 

redness,  and  upon  close  examination  the  enlarged  cutaneous  blood- 
vessels are  seen  as  delicate  or  coarse  red  lines,  running  superficially 
over  the  skin  in  an  irregular  and  tortuous  course.  Shortly  afterward 
there  are  developed  upon  the  hyperemic  and  hypertrophied  skin, 
papules  (acne  papulosa)  and  pustules  (acne  pustulosa),  their  nujnber 
never,  however,  being  very  great.  This  constitutes  true  acne 
rosacea.  The  disease  may  remain  in  this  state,  or,  rarely,  the  cu- 
taneous tissues  become  greatly  hypertrophied,  the  blood-vessels 
enormously  dilated,  the  glands  enlarged,  and  the  connective  tissue 
undergoes  hyperplasia,  resulting  in  permanent,  dark-red,  bulky 
formations,  the  shape  of  the  nose  being  contorted  into  various 
irregular  forms  {rhinophyma). 

Diagnosis. — The  affection  may  usually  be  distinguished  from  other 
affections  by  the  dilatation  of  the  blood-vessels,  the  acne,  papules, 
pustules,  and  tubercles,  and  the  tendency  to  overgrowth  of  the  con- 
nective tissue.     The  course  is  chronic  and  ulceration  never  occurs. 

Prognosis. — In  the  early  stages,  considerable  benefit  may  be 
afforded  by  appropriate  treatment.  Persistence  of  the  milder 
forms  of  the  disease  can  usually  be  traced  to  a  disinclination  on 
the  part  of  the  patient  to  carry  out  the  treatment.  In  the  occurrence 
of  connective-tissue  hypertrophy,  the  prognosis  as  to  cure  becomes 
less  favorable. 

Treatment. — As  in  simple  acne,  a  great  portion  of  the  treatment 
should  be  directed  toward  the  digestive  tract.  Tea,  coffee,  and 
alcohol  should  be  positively  prohibited.  The  remedies  advised 
in  acne  vulgaris  are  also  applicable  in  this  condition.  Extract 
of  thyroid  gland,  gr.  j  to  ij  (0.065  to  0.13  gm.),  three  times  daily,  over 
a  long  period  has  been  of  benefit. 

Locally,  sulphur  preparations,  particularly  lotio  alba  and  Kummer- 
f eld's  lotion  (see  page  692)  are  especially  valuable.  Resorcin  lotion, 
gr.  V  to  X  (0.35  to  0.6  gm.),  to  the  ounce,  is  of  benefit  in  some  cases. 
The  following  may  be  used: 

I^.     Hydrargyri  chlor.  corrosiv.   gr.  ij  0.13  gm. 

Petrolat B  j  .  32 .  o    gm. 

M.  S. — Apply  thoroughly. 
Or  the  following  suggested  by  G.  H.  Fox: 

I^.     Chrysarobini 5ss  2 .  o    gm. 

Collodii f  §  j  30  •  Q    c.c. 

M.  S. — Put  a  brush  through  the  cork  and  paint  lesions  every 
evening. 


SYCOSIS  VULGARIS  695 

For  the  second  stage  stronger  applications  are  usually  required. 
The  dilated  capillaries  should  be  incised  with  a  sharp  knife,  in  the 
hope  that  adhesive  inflammation  may  close  the  caliber  of  the  vessels, 
cold  water  compresses  being  used  to  control  the  bleeding,  a  few  of 
the  dilated  vessels  being  thus  treated  every  day  or  two,  until  all  have 
been  incised.     Electrolysis  has  also  been  recommended, 

Vleminckx's  solution  may  be  employed  in  some  cases : 

I^.     Calais Bss  16  gm. 

Sulph.  sublimat §j  32  gm. 

Aquas fBx  310  c.c. 

M.     Boil  to  6.  ounces  and  filter. 

S. — Add  I  part  of  the  solution  to  10  parts  of  water  and  apply 
locally. 

SYCOSIS  VULGARIS 

Definition. — A  chronic  inflammatory  disease  of  the  bearded  region, 
due  to  invasion  of  the  hair-follicles  by  pus-producing  niicroorganisms, 
characterized  by  papules,  pustules,  and  tubercles. 

Causes. — The  affection  usually  occurs  on  the  upper  lip,  and  is 
often  secondary  to  nasal  discharge.  The  exciting  cause  is  some  form 
of  staphylococcus. 

Pathology. — The  disease  consists  of  an  inflammation  within  and 
around  the  follicles  as  is  shown  by  the  presence  of  hair  in  each  of  the 
lesions. 

Symptoms. — The  manifestations  consist  of  pea-sized  papules  and 
pustules,  each  perforated  by  a  hair.  The  interfoUicular  spaces  are 
free  from  involvement  by  these  lesions  but  may  be  swollen  and  infil- 
trated. The  lesions  dry,  forming  crusts,  and  are  attended  by  itching, 
burning,  and  slight  pain.  The  hairs  remain  firmly  attached  except 
in  the  occurrence  of  marked  suppuration.  The  upper  lip  is  the  most 
common  seat,  but  other  portions  of  the  beard  may  be  attacked.  The 
affection  is  very  chronic. 

Diagnosis. — Care  should  be  taken  not  to  confuse  sycosis  vulgaris 
with  tinea  sycosis  or  ringworm  of  the  beard.  In  the  former,  there  are 
discrete  papules  and  pustules  at  the  sites  of  the  follicles;  the  hairs  are 
firmly  attached,  as  a  rule;  the  course  is  chronic;  the  upper  lip  is  most 
often  involved;  and  there  is  no  fungus. demonstrable. 

Pustular  eczema  may  be  distinguished  from  sycosis  by  its  more 
general  distribution  (not  limited  to  the  follicles),  its  oozing  character, 
and  its  diffuse  inflammatory  base. 


696  ■  PSORIASIS 

Prognosis. — The  disease  is  very  chronic  and  recurrences  are  com- 
mon. Persistence  in  the  treatment  is  usually  attended  by  great 
benefit. 

Treatment. — ^Local  applications  are  of  greatest  value.  The  hairs 
should  be  kept  very  short  either  by  clipping  or  shaving.  When  there 
is  marked  suppuration  the  affected  hairs  should  be  extracted  by 
forceps.  If  the  surface  is  acutely  inflamed  a  saturated  solution  of 
boric  acid,  zinc  oxide  ointment,  or  other  sedative  preparation  should 
be  applied.  Usually,  sulphur  ointment  ( 3  j  to  the  ounce)  is  of  most 
value.  It  should  be  rubbed  in  freely  night  and  morning.  Ammoni- 
ated  mercury,  ichthyol,  and  bichloride  of  mercury  are  also  useful  at 
times. 

Lupoid  sycosis  is  a  rare  form  of  the  disease  which  terminates  in 
scarring  and  atrophy  of  the  hair-follicles.  It  is  essentially  chronic 
and  seldom  responds  to  treatment. 

PSORIASIS 

Sjmonym. — Lepra  (used  by  early  writers). 

Definition. — A  chronic  affection  of  the  skin,  characterized  by 
reddish,  more  or  less  thickened  and  elevated,  dry,  inflammatory,  and 
somewhat  wrinkled  patches,  variable  as  to  size,  shape,  and  number, 
and  covered  with  abundant  whitish  or  grayish  colored,  imbricated 
scales. 

Cause. — Not  known.  The  source  of  the  affection  is  probably 
limited  to  the  skin  itself.  Gout,  rheumatism,  heredity,  and  parasitic 
infection  are  believed  to  be  causal  factors.  It  occurs  in  the  robust 
and  in  the  feeble,  and  in  both  males  and  females.  It  usually  appears 
in  early  life,  and  recurs  at  intervals  for  years.     It  is  not  contagious. 

Pathology. — ''The  disease  is  essentially  a  hyperplasia  of  the  normal 
constituents  of  the  Malpighian  layer  (mucous  layer).  The  increase 
takes  place  chiefly  in  the  interpapillary  portion  of  the  layer,  the  growth 
of  which  is  downward  causes  an  apparent  increase  in  size  of  the  papillae 
of  the  corium,  which,  however,  on  closer  examination,  is  found  not 
to  be  enlarged.  In  the  later  stages  of  the  disease  the  more  super- 
ficial blood-vessels  of  the  corium  become  dilated,  a  more  or  less  con- 
siderable emigration  of  the  white  blood  corpuscles  takes  place,  and 
the  immediate  neighborhood  of  the  vessels,  together  with  the  connect- 
ive tissue  of  the  corium,  becomes  the  seat  of  a  round-cell  infiltration, 
which,  with  the  effusion  of  serum,  separates  the  connective-tissue 
bundles  and  fibers  into  an  open  mesh  work.     During  the  period  of  dis- 


PSORIASIS  697 

appearance  of  the  disease  there  is  a  gradual  return  to  the  normal  con- 
dition, until  the  hyperplasia,  dilatation  of  the  blood-vessels,  and  cell 
infiltration  has  completely  disappeared.  The  hair  in  psoriasis  is 
affected  from  the  beginning  of  the  disease,  hyperplasia  of  the  external 
root-sheath,  the  structure  corresponding  to  the  Malpighian  layer  of 
the  epidermis,  taking  place,  with  extension  of  the  hyperplastic 
structure,  into  the  surrounding  cutis.  The  sebaceous  and  sweat- 
glands  are  not  at  any  time  affected"  (Robinson). 

Symptoms. — Psoriasis  begins  as  small,  reddish  spots  of  the  size  of  a 
pin-head,  which  immediately  become  covered  with  scanty  or  abun- 
dant whitish  or  grayish  imbricated  scales.  The  spots  gradually 
increase  in  diameter  by  peripheral  extension,  forming  patches  of 
various  sizes  and  shapes. 

If  an  attempt  be  made  to  detach  one  of  the  scales  by  means  of  the 
finger-nail,  it  will  be  found  to  adhere  quite  firmly  to  the  skin,  and  to 
be  about  the  thickness  of  a  card-board.  If  the  reddish  patch  thus 
made  bare  be  pinched  up  between  the  finger  and  thumb,  and  com- 
pared with  a  similar  pinch  of  the  healthy  skin,  its  inflammatory 
thickening  will  be  discerned.  A  punctate  hemorrhage  often  follows 
removal  of  the  scales  by  scratching.  There  is  no  watery  discharge  at 
any  time.     The  skin  between  the  patches  is  perfectly  healthy. 

While  the  anatomical  lesions  are  always  identical,  the  eruption 
assumes  such  features,  in  the  size  and  shape  of  the  patches  as  to  give 
rise  to  special  names : 

Psoriasis  Punctata. — The  eruption  occurs  as  small,  rounded  patches, 
about  the  size  of  a  pin's  head.  This  is  a  rare  variety.  The  lesion 
rapidly  increases  in  size. 

Psoriasis  Guttata. — The  eruption  occurs  in  the  form  and  size  of 
drops,  and  when  covered  with  scales  gives  the  skin  the  appearance  of 
having  been  splashed  with  mortar.     A  quite  frequent  variety. 

Psoriasis  Nummularis. — The  eruption  resembles  variously  sized 
coins. 

Psoriasis  Circinata. — The  eruption  is  about  the  size  of  the  former 
variety,  the  center  clearing  away,  leaving  the  skin  normal,  although 
it  may  continue  to  enlarge  at  the  periphery,  after  the  manner  of 
tinea  circinata. 

Psoriasis  Gyrata. — The  eruption  in  wavy  lines,  of  the  width  of  about 
half  an  inch,  resembling  circles  and  semicircles.  This  variety  is  a 
continuation  of  the  former,  from  the  joining  of  the  patches  of  psoriasis 
circinata. 


698  PSORIASIS 

Psoriasis  Difusa.—The  patches  of  eruption  are  large  and  of  irregu- 
lar shape,  covering  a  considerable  amount  of  surface.  This  variety 
occurs  more  frequently  on  the  front  of  the  leg  and  the  outer  aspect  of 
the  forearm. 

Psoriasis  Palmaris  et  Plantaris. — In  these  lesions  the  eruption  is 
characterized  by  larger,  thicker,  and  less  lustrous  scales,  and  by  the 
occurrence  of  deep  and  painful  fissures,  from  which  exudes  either  a 
serous  or  sanguineous  fluid. 

Psoriasis  Unguium. — In  psoriasis  of  the  nails  they  become  thick- 
ened, opaque,  grayish  in  color,  deeply  grooved  transversely,  and  often 
pitted,  and  in  rare  cases  the  nails  are  replaced  by  a  scaly  incrustation. 

Any  portion  of  the  body  is  liable  to  be  attacked  with  psoriasis,  but 
the  elbows,  knees,  and  scalp  are  involved  with  greatest  frequency. 
The  only  discomfort  the  patient  suffers  is  from  the  itching,  which  at 
times  is  very  severe  and  distressing.  The  disease  is  essentially  chronic. 
Few  cases  become  permanently  cured,  but  the  affection  shows  spon- 
taneous improvement  in  the  summer  months  in  many  cases.  The 
eruption  may  partially  or  completely  disappear  with  or  without 
treatment,  but  recurrence  is  to  be  expected. 

Diagnosis. — A  typical  attack  of  psoriasis  presents  no  difficulty  in 
diagnosis.  There  are  a  few  affections,  however,  which  may  be  con- 
founding in  irregular  cases. 

Squamous  eczema  occurring  in  patches  may  be  confused  with 
psoriasis.  In  the  former  the  tendency  is  to  involve  flexor  surfaces, 
itching  is  severe,  the  patches  are  irregular  and  do  not  clear  in  the 
center,  there  is  usually  a  history  of  moisture,  there  are  no  silvery  im- 
bricated scales,  and  there  is  decided  infiltration  and  thickening. 

Papulosquamous  syphilis  may  be  distinguished  from  psoriasis  by 
its  history,  concomitant  signs,  distribution,  absence  of  itching,  multi- 
formity of  the  lesions,  scanty  scaling,  and  deep-seated  infiltration. 

Tinea  circinata  is  characterized  by  more  inflammatory  lesions  and 
the  presence  of  the  fungus  in  the  scales  which  are  not  abundant. 

Seborrhea  of  the  scalp  and  psoriasis  of  the  same  region  are  frequently 
confounded.  In  the  former  the  scalp  is  paler,  the  scales  are  finer, 
smaller,  more  generally  diffused,  of  a  grayish  or  yellowish  color,  and 
greasy,  sebaceous  character.  Psoriasis  of  the  scalp  occurs  in  patches, 
which  are  reddish  and  infiltrated,  and  there  are  almost  always 
patches  of  the  disease  on  other  parts  of  the  body. 

Prognosis. — Removal  of  the  eruption  is  by  no  means  difficult. 
Relapses  are  common.     A  permanent  cure  can  never  be  assured. 


PSORIASIS  699 

Treatment. — The  constitutional  treatment  includes  attention  to  the 
diet  and  hygiene  and  the  relief  of  any  rheumatic,  gouty,  or  gastro- 
intestinal disorders.  A  low  protein  diet  is  indicated;  meat,  fish,  fowl, 
eggs,  liver,  etc.,  shall  be  avoided.  The  most  valuable  remedy  is 
arsenic,  either  in  solution  or  pill  form,  but  it  should  not  be  adminis- 
tered when  the  eruption  is  markedly  inflammatory.  Potassium 
iodide,  salicylates  (particularly  salicin),  thyroid  extract,  mercury, 
and  the  alkalies  are  of  benefit  in  certain  cases. 

Locally,  the  scales  should  first  be  removed  by  bathing  or  by  means 
of  unctuous  substances.  In  the  early  stage  when  the  symptoms  are 
highly  inflammatory,  soothing  applications  are  to  be  employed. 
Usually  stimulation  is  required  and  for  this  purpose  tar  is  of  great 
value.     The  following  is  frequently  employed: 

I^.     Olei  cadini 3j  4  gm. 

Petrolat §j  32  gm. 

M.  S. — Apply  locally  twice  daily. 

Or— 

I^.     Olei  cadini, 

Olei  amygdalae  dulc aa   5ss  16  c.c. 

M.  S. — Apply  locally  twice  daily. 
Or— 

I^.     Ung.  picis  (U.S.P.) 5j  4  gm. 

Petrolat §j  32  gm. 

M.  S. — Apply  locally  twice  daily. 

The  following  formula  suggested  by  G.  H.  Fox  is  of  benefit: 

I^.     Chrysarobini gr.  x  to  xx  to  5  j  o  •  65  to  i .  3  to  4  gm 

^theris  et  alcoholis . . .  aa  q.  s.  q.  s. 

CoUodii f §j  30  c.c. 

M.  S. — Rub  the  chrysarobin  with  a  little  alcohol  and  ether, 
and  add  to  the  collodion.  Apply  to  the  affected  patch  by  means 
of  a  camel's-hair  brush,  after  removal  of  the  scales. 

The  objection  to  chrysarobin  in  ointment  form  is  that  it  stains  the 
clothing;  the  following,  however,  may  be  employed  with  good  results: 

I^.     Chrysarobini gr.  x  to  xv  to  xxx  o .  6  to  I  to  2  gm. 

Petrolat §  j  32 .0  gm. 

M.  S. — Apply  to  each  spot  twice  daily. 
In  using  chrysarobin,  care  should  be  taken  not  to  have  the  prepara- 


700  PITYRIASIS   ROSEA 

tion  of  too  great  a  strength  and  not  to  apply  it  over  too  large  an  area, 
otherwise  a  dermatitis  may  result. 

Among  other  local  remedies  of  value  may  be  mentioned  sulphur, 
ammoniated  mercury,  salicylic  acid,  green  soap,  pyrogallic  acid,  and 
resorcin.  The  application  of  the  ac-ray  is  of  benefit  in  removing  the 
lesions  but  has  no  effect  in  preventing  recurrence. 

PITYRIASIS  ROSEA 

Synonyms. — Pityriasis  maculata  et  circinata;  herpes  tonsurans 
maculosus. 

Description. — An  acute,  self -limited,  inflammatory  disease,  char- 
acterized by  the  appearance  of  pinkish  or  rose  colored  macules  and 
maculopapules  occurring  in  oval  patches  occupying  chiefly  the  trunk 
and  thighs.  Many  of  the  patches  tend  to  clear  up  in  the  center  and 
spread  at  the  periphery.  The  central  portion  of  each  patch  presents 
a  somewhat  yellowish  appearance  while  the  border  is  pinkish,  elevated, 
and  covered  with  small  scales.  Slight  itching  may  be  present.  The 
affection  may  be  attended  by  mild  constitutional  reaction.  The 
course  is  from  four  to  eight  weeks,  the  eruption  undergoing  involution 
spontaneously  and  being  uninfluenced  by  treatment.  The  course, 
location,  and  character  of  the  lesions  will  distinguish  this  eruption 
from  other  circinate  diseases,  such  as  psoriasis,  seborrheic  eczema, 
syphilis,  and  ringworm. 

DERMATITIS 

Inflammation  of  the  skin  as  the  result  of  local  irritation.  The 
symptoms  are  the  ordinary  phenomena  of  inflammation  in  general, 
redness,  heat,  swelling,  pain,  and  tenderness. 

Dermatitis  traumatica  is  that  form  of  the  affection  due  directly 
to  local  injury. 

Dermatitis  calorica  is  the  variety  which  is  produced  by  exposure 
to  extremes  of  heat  (burns)  or  cold  (frost-bite).  Various  grades 
of  reaction  are  observed  according  to  the  severity  of  the  exposure. 
Three  stages  occur  in  both  forms,  erythema,  vesication,  and  gangrene. 

Treatment. — For  burns,  a  solution  of  sodium  bicarbonate  or 
Carron  oil  (equal  parts  of  linseed  oil  and  lime-water)  is  of  great 
value;  so,  too,  is  a  i  per  cent,  solution  of  picric  acid.  For  frost-bite, 
first  rubbing  the  part  with  snow  and  later  applying  ichthyol  ointment 
( 3  j  to  the  ounce)  is  a  very  efficient  mode  of  treatment. 


DERMATITIS  70I 

Dermatitis  venenata  is  the  form  of  the  condition  that  arises  from 
contact  with  poisonous  plants  and  chemical  irritants.  The  most 
common  variety  of  this  is  that  following  exposure  (in  susceptible 
individuals)  to  the  poison  ivy  (rhus  toxicodendron),  poison  oak 
(rhus  venenata),  and  posion  sumach  (rhus  diversibola) .  Among 
other  plants  capable  of  inducing  this  condition  may  be  mentioned 
the  trumpet  vine,  dogwood,  common  radishes,  common  field  daisy, 
star  cucumber,  and  certain  fungi.  Among  irritant  drugs  frequently 
inducing  this  inflammation  are  mustard,  croton  oil,  cantharides, 
iodoform,  dye-stuffs,  tobacco,  arnica,  liniments  of  various  kinds, 
turpentine,-  acids,  alkalies,  etc.  Any  substance  employed  for  the 
treatment  of  disease  of  the  skin  when  used  in  excess  may  cause  the 
condition.  Individuals  engaged  in  trades  necessitating  the  constant 
handling  of  flour,  sugar,  pastes,  and  similar  substances  frequently 
develop  this  affection.  Excessive  exposure  to  the  x-ray  or  Finsen 
lamp  gives  rise  to  dermatitis.  Many  other  substances,  not  men- 
tioned here,  may  induce  an  artificial  inflammation  if  the  integu- 
ment is  susceptible  to  their  influence. 

Sjrmptoms. — The  earliest  manifestation  is  diffuse  erythema. 
If  the  irritation  was  not  very  severe  the  affection  may  subside  after 
the  occurrence  of  erythema  and  slight  swelling.  Usually,  however, 
the  swelling  becomes  more  intense  and  innumerable  vesicles  and 
blebs  form  on  the  affected  regions,  accompanied  by  almost  intolerable 
burning  and  itching.  In  the  ordinary  case  due  to  rhus  poisoning, 
the  hands,  face,  and  genitalia  are  the  regions  most  often  involved. 
These  symptoms  usually  subside  spontaneously  within  a  week  or 
ten  days,  but  may  be  prolonged  by  continued  exposure  and  improper 
treatment. 

Treatment. — In  all  cases,  the  irritant  should  be  withdrawn  at 
once.  Sedative  lotions  are  most  efficacious  in  subduing  the  inflam- 
mation. One  of  the  most  soothing  is  a  saturated  aqueous  solution 
of  boric  acid  containing  ten  minims  (0.6  c.c),  of  glycerin  to  the 
ounce.  Sodium  hyposulphite  solution-  (3j  to  the  ounce),  dilute 
fluidextract  of  grindelia  robusta  (3  j  to  4  ounces  of  water),  and  lotio 
nigra  and  lime-water  are  also  very  beneficial.  The  itching  may  be 
relieved  by  the  addition  of  carbolic  acid  (10  minims  to  the  ounce) 
and  glycerin  (10  minims)  to  any  of  the  preparations.  The  great 
danger  lies  in  overt reating,  in  an  effort  to  allay  the  itching  and 
burning. 

Dermatitis  medicamentosa  is  the  term  applied  to  the  various 


702  DERMATITIS 

cutaneous  manifestations  that  are  due  directly  to  the  internal  ad- 
ministration of  certain  drugs.  This  form  is  influenced  by  individual 
susceptibility,  elimination  through  the  skin,  large  dosage,  and  long- 
continued  administration. 

The  bromides  produce  an  eruption  consisting  of  papules  and  pus- 
tules resembling  acne  in  many  respects  but  having  a  more  inflam- 
matory appearance.  Occasionally,  the  eruption  consists  of  macules, 
bullae,  and  even  fungating  nodules,  the  latter  being  most  common 
in  children. 

The  iodides  usually  give  rise  to  an  acneiform  eruption  but  may 
produce  bullous,  papular,  or  erythematous  cutaneous  manifestations. 

Cubebs  and  copaiba  in  susceptible  individuals  give  rise  to  erythema, 
macules,  and  papules,  the  eruption  often  resembling  urticaria  or 
erythema  multiforme. 

Antipyrine  and  other  coal-tar  products  are  not  infrequently  followed 
by  morbilliform,  erythematopapular,  or  urticarial  eruptions  which 
are  prone  to  itch  and  desquamate. 

Belladonna  and  its  alkaloid  atropine  occasionally  induce  a  diffuse 
erythematous  eruption  on  the  face,  neck,  and  chest  resembling 
scarlet  fever.  Associated  with  it  are  dryness  of  the  throat,  dilatation 
of  the  pupils,  and  mild  delirium. 

Arsenical  preparations  may  give  rise  to  urticarial,  erythematous, 
papular,  or  vesicular  manifestations.  Long-continued  administra- 
tion is  often  followed  by  pigmentation  of  the  skin. 

Chloral  occasionally  produces  an  erjrthematous  or  an  urticarial 
eruption. 

Quinine  in  susceptible  persons  may  be  followed  by  erythematous, 
urticarial,  purpuric,  or  vesicular  eruptions. 

Opium  and  its  derivatives  may  give  rise  to  pruritus,  erythema, 
papules,  or  wheals. 

Serums  employed  for  antitoxic  purposes  are  not  uncommonly 
followed  by  urticarial  eruptions. 

Dermatitis  factitia  is  the  term  applied  to  eruptions  produced  by 
the  patient  for  the  purpose  of  exciting  sympathy  or  attention. 
They  resemble  none  of  the  well-recognized  diseases  and  the  diagnosis 
is  always  difficult.  The  lesions  usually  occur  suddenly  on  accessible 
regions.     The  patients  are  mostly  hysterical  women  or  malingerers. 

Dermatitis  exfoliativa  is  a  very  unusual  affection,  in  which  the 
inflammation  is  attended  with  high  fever  and  followed  by  extensive 
desquamation. 


FURUNCULUS  703 

FURUNCULUS 

Synonyms. — Boil;  furuncle;  furunculosis. 

Definition. — An  acute  affection  of  the  skin,  characterized  by  the 
occurrence  of  one  or  more  circumscribed  cutaneous  or  subcutaneous 
abscesses  (boils),  which  usually  terminate  by  necrosis  of  the  central 
tissue,  with  its  subsequent  expulsion  in  the  form  of  pus  or  a  core,  and 
a  resulting  cicatrix. 

Causes. — The  exciting  cause  is  infection  of  the  hair-follicles  with 
pus-producing  microorganisms.  As  contributory  causes  may  be 
mentioned  general  debility,  anemia,  diabetes,  uremia,  local  friction 
or  injury,  uncleanliness,  and  contact  with  certain  irritants,  particu- 
larly tar  and  petroleum. 

Pathology.. — The  process  resulting  in  a  "boil"  has  its  origin  in 
either  a  sebaceous  gland,  a  sweat  gland,  or  a  hair-follicle,  and  never 
begins  in  the  meshes  of  the  corium.  "It  begins  as  a  small,  roundish 
spot  which  increases  in  size  until  certain  dimensions  are  attained, 
when  it  undergoes  suppurative  change,  resulting  in  the  formation  of 
a  central  point  or  core,  composed  of  the  tissue  of  the  gland  in  which 
the  furuncle  originated,  which,  together  with  the  pus,  is  cast  off. 
It  shows  no  disposition  to  become  diffuse,  being  always  a  circum- 
scribed inflammation.  After  the  discharge  of  the  core  a  cavity  of 
more  or  less  depth  remains,  showing  the  tissue  around  it  to  be  hard 
and  infiltrated.  After  a  few  days  or  a  week  it  fills  up  by  granulation, 
leaving  a  cicatrix  which  is  often  permanent .  The  central  point  or  core, 
when  thrown  off,  is  composed  of  a  whitish,  tough,  pultaceous  mass  of 
dead  tissue,  varying  in  size  with  the  extent  and  depth  of  the  inflamma- 
tion" (Duhring). 

The  staphylococcus  pyogenes  aureus  is  the  microorganism  respon- 
sible for  the  condition  in  most  cases.  The  tricophyton  fungus  is 
occasionally  the  exciting  cause. 

Symptoms. — "Boils"  may  occur  singly,  or  more  commonly  in 
crops  of  two,  three,  or  more,  another  crop  following  their  disappear- 
ance (furunculosis). 

The  abscess  begins  as  a  small,  rounded,  imperfectly  defined,  iso- 
lated, reddish  spot,  of  a  highly  inflamed  character,  painful  on  pres- 
sure, its  size  gradually  increasing,  its  central  point  presenting  evidences 
of  suppuration.  It  reaches  its  full  development  in  about  a  week, 
when  it  consists  of  a  slightly  raised,  rounded,  and  pointed  inflammatory 
swelling,  with  a  yellowish  point  in  the  center — the  "  core."  Abscesses 
with  no  central  suppuration  or  core  are  called  "blind  boils."     The 


704  '  CARBUNCDLUS 

size  of  a  developed  boil  varies  from  a  split-pea  to  a  walnut,  the  color 
deep  red,  with  a  yellow  center,  surrounded  by  a  slight  areola.  The 
pain  of  a  boil  is  dull  and  throbbing,  increased  on  pressure,  and  usually 
worse  at  night.  The  constitutional  symptoms  are  mild  or  severe, 
according  to  the  number  and  size  of  the  lesions. 

Any  portion  of  the  body  may  be  attacked;  its  preference,  however, 
is  for  the  face,  neck,  back,  axillae,  and  buttocks. 

Prognosis. — Single  lesions  usually  pass  through  their  course  without 
affecting  the  general  condition  of  the  patient,  Furunculosis  may  be 
very  difficult  to  relieve  and  may  impair  the  general  health. 

Treatment. — In  all  cases  of  continuous  furuncle  formation,  the 
urine  should  be  examined  and  any  organic  disease  promptly  treated. 
In  these  cases  tonics  such  as  iron,  quinine,  and  strychnine  should  be 
administered.  It  is  a  common  practice,  even  when  the  lesions  are 
single,  to  administer  calcium  sulphide,  gr.  ^0  to  H  X'^-'^^^S  ^^  0.008 
gm.),  every  two  or  three  hours.  The  efficacy  of  this  treatment  is 
doubtful.  Benefit  has  resulted  from  20  to  30  minim  doses  of  dilute 
sulphuric  acid  in  2  ounces  of  water  every  four  hours. 

Locally,  warm  applications  often  aid  in  hastening  suppuration, 
which  when  it  has  occurred  indicates  early  incision  to  allow  expulsion 
of  "the  core."  Shaving  of  the  hair  in  the  immediate  vicinity  fre- 
quently prevents  infection  of  adjacent  follicles.  If  the  lesion  is  ex- 
posed to  friction  it  should  be  protected  by  soap -plaster  or  adhesive 
plaster.  Among  the  various  methods  recommended  for  aborting 
furuncles  may  be  mentioned  crucial  incisions,  injection  of  2  to  5  drops 
of  carbolic  acid  (5  per  cent,  solution)  into  the  apex  of  the  boil,  and  the 
application  of  equal  parts  of  glycerin  and  extract  of  belladonna  or  the 
ointment  of  nitrate  of  mercury.  Ichthyol  ointment  (25  per  cent.) 
is  of  great  value.  Carbolized  vaseline  (5  per  cent.)  is  a  useful 
application. 

Vaccine  treatment  has  recently  been  tried,  and  with  considerable 
success. 

CARBUNCULUS 

Sjmonjnns. — Carbuncle;  anthrax  benigna. 

Definition. — An  indurated,  more  or  less  circumscribed,  dark  red, 
painful,  deep-seated  inflammation  of  the  skin  and  subcutaneous  con- 
nective tissue,  terminating  in  a  slough  and  the  subsequent  production 
of  a  permanent  cicatrix. 


CARBUNCULUS  705 

Causes. — The  exciting  cause  is  some  pathogenic  microorganism. 
The  affection  usually  occurs  in  middle-aged  individuals  and  in  men 
more  often  than  in  women.  Impairment  of  the  general  health,  dia- 
betes, and  local  injury  are  also  factors  in  its  production. 

Pathology. — Although  Billroth  regards  furuncle  and  carbuncle  as 
differing  only  in  degree,  the  explanation  of  Warren,  of  Boston,  seems 
the  more  probable,  he  being  the  first  to  call  the  attention  of  histolo- 
gists  "to  the  existence  of  small  columns  of  adipose  tissue  leading  from 
the  panniculus  adiposus  up  to  the  roots  of  the  lanugo  hairs,  taking  an 
oblique  direction  in  a  line  with  the  erectores  pilorum.  The  inflamma- 
tion resulting  in  suppuration  of  the  subcutaneous  adipose  tissue 
must  either  form  an  abscess  or  become  diffuse.  In  phlegmonous 
erysipelas  the  latter  condition  is  observed;  but  when  the  inflammation 
is  in  the  dermoid  texture,  the  exudates  infiltrate  the  skin  and  natu- 
rally follow  the  canals  occupied  by  the  'columnae  adipose.'  The 
pressure  thus  exerted  upon  the  dermoid  tissue  cannot  fail  to  strangu- 
late the  circulation  and  thus  produce  gangrene  of  the  tissue,  even  if 
the  exudate  be  not  poisonous  enough  to  destroy  the  cells  by  its  pres- 
ence. It  can  by  this  explanation  be  easily  understood  why  this  dis- 
ease is  apt  to  affect  the  skin  on  the  nape  of  the  neck  and  the  back 
more  than  on  other  parts  of  the  body.  At  this  point  the  skin  is  dense, 
its  fibrous  element  extending  deep  into  the  adipose  layer,  which  is 
surrounded  by  strong  bands;  hence,  the  pus  confined  in  such  a 
place,  seeking  the  easiest  outlet,  will  travel  along  these  miniature 
adipose  canals,  producing  the  peculiar  appearance  pathognomonic  of 
carbuncle." 

Symptoms. — The  affection  is  usually  manifested  by  a  single  lesion 
which  occurs  with  greatest  frequency  on  the  back  of  the  neck,  should- 
ers, or  between  the  scapulae.  It  begins  in  the  lower  layers  of  the  in- 
tegument and  it  first  resembles  a  phlegmon  but  is  devoid  of  its  bright 
redness.  It  is  surrounded  in  the  early  stages  and  vesicles  may  be 
present.  Soon  the  affected  area  becomes  firm,  circular,  flat,  and 
raised  above  the  surrounding  parts  with  painful  infiltration  of  the 
skin  and  subcutaneous  connective  tissue.  The  size  varies  from  a 
hazel  nut  to  an  orange  and  the  color  is  violaceous.  After  a  week  or 
ten  days,  the  constant  pressure  results  in  sloughing  of  the  overlying 
skin  at  numerous  points,  through  which  necrotic  masses  and  purulent 
material  are  discharged.  This  gives  the  lesion  a  cribriform  appear- 
ance which  is  especially  characteristic.  Later  the  entire  mass  termi- 
nates in  a  slough,  which,  on  being  detached,  leaves  a  large,  open,  deep 

45 


7o6  CARBUNCULUS 

ulcer  with  firm,  everted  edges  granulating  slowly,  a  permanent 
cicatrix  marking  the  site  of  the  lesion.  The  development  of  the 
carbuncle  is  attended  by  severe  pain  of  a  deep,  throbbing,  and 
burning  character. 

Anorexia,  coated  tongue,  general  malaise,  and  moderate  febrile 
reaction  accompany  all  cases  but  vary  according  to  the  size,  number, 
and  severity  of  the  lesions.  In  very  severe  cases,  symptoms  of  sep- 
ticemia are  superadded. 

Diagnosis. — The  characteristics  of  carbuncle  are  the  single  lesion, 
the  size,  the  phlegmonous  nature  of  the  inflammation,  the  cribriform 
appearance,  the  gangrenous  termination,  and  the  marked  constitu- 
tional disturbances. 

Prognosis. — The  outlook  is  never  very  favorable,  as  general 
septic  infection  is  liable  to  occur  at  all  times.  It  is  most  serious 
when  occurring  in  the  aged,  alcoholics,  diabetics,  and  greatly  de- 
bilitated subjects  and  when  situated  on  the  upper  lip  (an  unusual 
location).  In  ordinary  cases  the  prognosis  is  not  so  grave  but  the 
possibility  of  general  infection  should  always  be  borne  in  mind. 

Treatment. — Constitutional  treatment  is  of  great  importance. 
Nutritious  diet,  stimulants,  and  full  doses  of  remedies  such  as  tinc- 
ture of.  the  chloride  of  iron,  quinine  sulphate,  arsenic,  strychnine, 
and  ammonium  chloride  should  be  prescribed.  Calcium  sulphide, 
gr.  3^  (0.008  gm.),  every  two  hours,  is  of  benefit  in  some  cases. 
Opium,  chloral,  or  phenacetin  may  be  necessary  to  relieve  the  pain. 
Benefit  has  resulted  from  20  to  30  minim  doses  of  dilute  sulphuric 
acid  in  2  ounces  of  water,  every  four  hours. 

Locally,  the  injection  of  a  saturated  solution  of  pure  carbolic  acid 
through  the  several  apertures  of  the  lesion  in  every  direction  through 
the  sloughing  tissue,  is  often  very  beneficial.  It  produces  severe 
pain  for  a  short  time  afterward.  The  injection  of  10  to  20  minims 
of  a  5  per  cent,  solution  of  carbolic  acid  in.  glycerin,  into  the  lesion 
very  early  in  its  course,  may  serve  to  abort  it.  The  application  of 
stick  caustic  potash  directly  into  the  openings  of  the  carbuncle  is 
also  of  value.  Crucial  incision  may  be  employed  at  times.  Strap- 
ping of  the  lesion  by  means  of  adhesive  strips  applied  in  concentric 
squares,  painting  with  cantharidal  collodion  or  tincture  of  iodine,  or 
the  daily  application  of  nitrate  of  mercury  ointment  may  also  be  used. 
With  the  occurrence  of  necrosis,  hot  antiseptic  solutions  should  be 
applied  to  aid  in  separation  of  the  gangrenous  slough.  If  septicemia 
threatens  the  necrotic  tissues  should  be  excised. 

Vaccine  treatment  has  been  tried,  with  some  success. 


TINEA   CIRCINATA  707 

PARASITIC  DISEASES 

TINEA  CIRCINATA 

Synonyms. — Tinea  trichophytina  corporis;  herpes  circinatus; 
ringworm  of  the  body. 

Definition. — A  contagious,  vegetable  parasitic  affection  of  the 
skin,  due  to  the  trichophyton  fungus,  characterized  by  the  develop- 
ment of  one  or  more  circular  or  irregularly  shaped,  variously  sized, 
inflammatory,  slightly  vesicular  or  squamous  patches,  occurring 
upon  the  general  surface  of  the  body. 

Causes. — Ringworm  of  the  body  is  caused  by  the  presence  of  a 
vegetable  parasite,  termed  the  trichophyton,  the  same  growth  or 
fungus  that  produces  tinea  tonsurans  and  tinea  sycosis.  The 
affection  is  highly  contagious  and  is  frequently  communicated  from 
one  individual  to  another,  although  it  has  been  determined  that 
a  certain  unknown  condition  of  the  skin  is  requisite  for  its  develop- 
ment. The  domestic  pets,  chiefly  cats  and  dogs,  are  a  common  source 
of  infection.  In  children  it  is  most  frequently  seen  among  the 
weakly  and  the  poorly  nourished.  In  adults  it  is  usually  associated 
with  a  decline  in  the  general  health. 

Pathology. — The  fungus  is  seated  between  the  strata  of  the  epi- 
dermis, more  particularly  in  the  superior  layers  of  the  rete.  My- 
celium, consisting  of  long,  slender,  jointed  threads  may  be  found  in 
abundance  but  spores  are  very  scant.  The  presence  of  this  foreign 
body  produces  the  subsequent  phenomena — a  superficial  dermatitis, 
erythema,  exudation,  minute  vesiculation,  and  papulation,  and  in 
the  severe  grades,  tubercles  and  pustules.  The  desquamative 
symptoms  are  exfoliative — nature's  efforts  for  relief. 

S3niiptoms. — Tinea  circinata  varies  greatly  in  the  degree  of  its 
development,  from  the  trivial  complaint  so  often  seen  in  children 
to  the  chronic,  extensive,  and  obstinate  disease  sometimes  seen  about 
the  thighs  in  adults  {tinea  circinata  cruris) . 

The  disease  usually  begins  as  a  small,  reddish,  scaly,  rounded  or 
irregularly  shaped  spot  of  papules,  which  in  a  very  few  days  assumes 
a  circular  form  (ringworm).  It  continues  to  increase  in  size,  the 
papules  often  changing  to  vesicles.  A  characteristic  of  the  eruption 
is  its  healing  in  the  center  as  it  spreads  at  the  periphery.  Occasion- 
ally the  circles  or  rings  coalesce,  forming  serpiginous  lesions.  The 
usual  size  of  a  fully  developed  ringworm  is  about  that  of  a  silver 
quarter  of  a  dollar.     The  affection  occurs  with  greatest  frequency 


7o8  TINEA   CIRCINATA 

Upon  the  face,  neck,  and  backs  of  the  hands.     Itching  is  slight  as  a  rule. 

Chronic  tinea  circinata  often  lacks  the  characteristic  annular 
configuration,  but  instead  appears  in  the  form  of  single  or  mul- 
tiple, disseminated,  small,  reddish,  slightly  scaly,  ill-defined  spots 
which  may  or  may  not  be  elevated  above  the  surrounding  skin.  The 
size  varies,  and  the  line  of  demarcation  between  the  lesion  and  the 
healthy  skin  may  be  lacking. 

The  "eczema  marginatum"  of  Hebra  is  to  be  looked  upon  as  a 
severe  form  of  tinea  circinata. 

Tinea  circinata  cruris,  or  ringworm  of  the  thighs,  a  variety  of  the 
"eczema  marginatum"  of  Hebra,  is  usually  complicated  with  true 
eczema,  and  is  a  very  obstinate,  chronic  form  of  the  affection;  it  is 
accompanied  by  severe  itching. 

Tinea  trichophytina  unguium  is  a  variety.  The  nails  become 
opaque,  whitish,  thickened,  and  soft  and  brittle,  especially  along 
their  free  border.     Its  course  is  chronic,  and  it  is  difficult  to  cure. 

Diagnosis. — While  in  many  cases,  the  history,  course,  character 
of  the  eruption,  etc.,  will  serve  to  distinguish  tinea  circinata  from  other 
circinate  eruptions,  the  diagnosis  should  always  be  rendered  positive 
by  a  microscopic  examination  of  the  scales  removed  from  the  lesion. 
The  scales  should  be  placed  upon  a  glass  slide  containing  a  drop  of 
liquor  potassse  over  which  is  laid  a  thin  glass  cover.  After  remain- 
ing for  a  few  minutes,  the  fungus  may  be  detected  by  a  microscope 
having  a  magnifying  power  of  from  250  to  500  diameters. 

Prognosis. — The  affection  is  usually  very  amenable  to  treatment 
but  occasionally  it  exhibits  great  obstinacy.     At  times  relapses  occur. 

Treatment. — Local  applications  usually  suffice  to  cure  the  affection. 
The  patch  should  be  washed  with  soap  and  water  and  one  of  the 
following  applied: 

I^.     Cupri  acetat gr.  x  0.6  gm. 

Ung.  aquae  rosae §i  32.0  gm, 

M.  S. — Apply  locally  twice  daily. 
Or— 

Ei,     Hydrargyri  ammoniat gr.  xx  to  xxx  i  .3  to  2  gm, 

Petrolat Bj  32  gm, 

M,  S, — Apply  locally  twice  daily. 
Or— 

I^,     Hydrargyri  chloridi  cor. ...   gr.  j  0.065  gni- 

Tinct.  benzoin,  comp f  §j  30.0      c.c. 

M,  S. — Apply  twice  daily. 


TINEA   TONSURANS  709 

Or— 

I^.     Sulph.  praecip 3j  4  gm- 

Acid,  boric 5j  4  gm. 

Petrolat 5j  32  gm. 

M.  S. — Apply  locally  twice  daily. 
Or— 

I^.      Sodii  hyposulphit 5j  4  gni- 

Aquse f  5J  30  c.c. 

M.  S. — Apply  locally  twice  daily. 

Among  other  remedies  of  value  may  be  mentioned  tar,  resorcin, 
betanaphthol,  chrysarobin,  protargol,  and  sublamine. 

In  obstinate  cases  of  tinea  cruris,  the  parts  should  be  treated 
with  a  saturated  solution  of  boric  acid  and  afterward  covered  with 
boric-acid  powder  or  ammoniated  mercury  ointment  (gr.  xxx  to  5  J)- 

TINEA  TONSURANS 

Synonjmis. — Tinea  trichophytina  capitis;  herpes  tonsurans; 
ringworm  of  the  scalp. 

Definition. — A  contagious,  parasitic  affection  of  the  scalp,  due 
to  the  trichophyton  fungus,  characterized  by  the  development  of 
circumscribed,  vesicular  or  squamous,  more  or  less  bald  patches 
in  which  the  hair  is  diseased  and  usually  broken  off  close  to  the  scalp. 

Cause. — It  results  from  the  presence  and  growth  of  the  same 
fungus  which  gives  rise  to  tinea  circinata — trichophyton.  It  is  an 
affection  of  childhood,  seldom  being  seen  after  puberty.  It  is  highly 
contagious,  and  may  be  contracted  from  a  case  of  ringworm  of  the 
body. 

Pathology. — The  fungus  invades  the  hair,  hair-follicles,  and  ad- 
jacent epidermis  causing  disintegration  of  the  hair  and  distention 
of  the  follicle  which  becomes  prominently  raised.  Spores  are  present 
in  abundance  but  the  mycelium  is  very  scant.  The  hair-shaft  is 
fractured  just  above  the  level  of  the  scalp,  and  usually  presents  a 
jagged,  bristly,  stubble-like  extremity.  The  epidermis  of  the  scalp 
may  either  present  minute  vesicles  and  desquamation,  or,  in  severe 
cases,  edema  and  inflammatory  symptoms,  with  fluid  exudation 
{tinea  kerion). 

Sjrmptoms. — Ringworm  of  the  scalp  usually  begins  in  the  form  of 
small  circumscribed  patches,  which  soon  become  the  seat  of  small 
vesicles  or  pustules,  terminating  in  desquamation,  or  of  furfuraceous 


yiO  TINEA   TONSURANS 

scales.  The  patches  spread  rapidly,  soon  reaching  the  size  of  a 
silver  quarter  to  that  of  a  silver  dollar.  They  are  circular  in  form, 
circumscribed,  of  a  reddish,  grayish,  or  greenish-yellow  color,  and 
covered  with  fine  or  coarse  scales,  with  the  hairs  broken  off  close  to 
the  scalp.  The  epidermis  of  the  scalp  is  more  or  less  raised,  and  the 
follicles  are  prominent,  giving  the  characteristic  appearance  of  the 
disease — the  goose-skin  or  plucked-fowl  appearance.  As  a  result  of 
the  loss  of  hair,  baldness,  more  or  less  complete,  but  temporary, 
exists.     Itching  is  a  constant  symptom. 

Ringworm  of  the  face  or  body  {tinea  circinata)  may  complicate 
tinea  tonsurans. 

Tinea  kerion  is  a  severe  variety  of  tinea  tonsurans,  ''characterized 
by  edema,  inflammation,  and  the  exudation  of  a  viscid,  glutinous, 
yellowish  secretion  from  the  opening  of  the  hair-follicles.  When 
fully  developed  the  patches  are  yellowish,  reddish,  or  purple  in  color, 
and  are  more  or  less  raised,  edematous,  and  boggy.  They  are  uneven 
and  honeycomb -like  (hence  the  name  kerion),  and  studded  with 
yellowish,  suppurative  points,  or,  later  with  small  cavities  or  foramina, 
the  openings  of  the  distended  hair-follicles  deprived  of  their  hairs, 
which  discharge  a  mucoid,  gummy,  honey-like  fluid."  The  patches 
are  tender,  painful,  and  at  times  the  seat  of  itching. 

Diagnosis. — The  affection  is  usually  readily  differentiated  from 
other  diseases  of  the  scalp  by  its  occurrence  in  children,  in  the  shape 
of  circumscribed,  sharply  marginated,  more  or  less  circular  patches 
of  incomplete  baldness  characterized  by  broken-off  hairs,  very  promi- 
nent follicles,  and  grayish  scales.  The  presence  of  the  fungus  is 
diagnostic.  A  hair  should  be  extracted,  and  examined  after  being 
immersed  in  liquor  potassse. 

Prognosis. — The  disease  is  essentially  chronic.  If  untreated 
it  may  persist  for  two  or  three  years  or  until  puberty,  when  its  soil 
seems  to  be  exhausted  and  the  affection  subsides.  Even  under 
treatment  the  patches  may  last  for  six  months  or  more. 

Treatment. — Local  treatment  only  is  required,  and  it  should 
be  vigorous  and  persistent.  No  case  should  be  discharged  until  the 
microscope  shows  absence  of  the  fungus  in  the  extracted  hairs. 
Mild  cases  should  be  treated  by  cutting  the  hair  as  close  as  possible 
and  thoroughly  scrubbing  the  patches  with  green  soap  and  water 
or  by  the  application  of  a  25  to  50  per  cent,  solution  of  boroglycerin, 
twice  daily,  or  a  6  per  cent,  solution  of  the  oleate  of  mercury,  or  one 
of  the  following: 


TINEA   TONSURANS  711 

I^.     Sulph.  praecip 5  j  4  gm- 

Petrolat 5j  32  gm. 

M.  S. — Apply  locally  twice  daily. 

I^.     Betanaphthol 5j  4  gm- 

Petrolat Bj  32  gm. 

M.  S. — Apply  locally  twice  daily. 

I^.     Protargol gr.  xxiv  i .  5  gm. 

Petrolat 5j  32.0  gm. 

M.  S. — Apply  locally  twice  daily. 

I^.     Sodii  borat 5j  4  gn^- 

Aquae  destil f  Si]  60  c.c. 

M.  S. — Apply  thoroughly  several  times  daily. 

I^.     Acid,  boric gr.  xv  I  gm. 

Sulph.  flor gr.  XV  I  gm. 

Petrolat B  jss  47  gm. 

M.  S. — Apply  to  scalp  night  and  morning. 

I^.     Cupri  oleat 5ss  2  gm. 

Petrolat §ij  63  gm. 

M.  S. — Apply  locally  after  washing  the  scalp  with  boric  acid 
solution. 

A  preparation  very  popular  in  London,  known  as  Coster's  paste, 
is  used  by  painting  the  patches  with  a  brush  and  allowing  it  to  remain 
on  until  the  crust  is  cast  off  in  the  course  of  five  or  six  days,  when  it 
may  be  reapplied.     A  few  applications  suffice.     Its  formula  is: 

I^.     lodin 3ij  8  gm. 

Olei  picis f  §j  30  c.c. 

M.  S. — Apply  as  directed. 

An  excellent  application  is — 

I^.     Ung.  acid,  borici 5ij  63  gm. 

Ung.  eucalyptol §ij  63  gm. 

01.  caryophylli f  5ss  2  c.c. 

Glycerin! q.  s.  q.  s. 

M.     Ft.  ung. 

S. — Apply  locally. 

Cases  which  resist  these  means  are  to  be  treated  by  removing  the 
loose  hairs  about  the  edges  of  the  patches  and  the  broken-off  hairs 
over  the  surface,  by  means  of  small,  broad-bladed,  short  forceps,  a 
few  hairs  only  being  seized  at  a  time,  a  portion  of  the  diseased  hairs 


712  TINEA    SYCOSIS 

being  removed  each  day  until  the  surface  has  been  cleared.  After 
each  depilation  one  of  the  above  formulae  should  be  applied.  The 
%-ray  has  been  used  with  marked  success  by  Sabouraud  of  Paris,  and 
others. 

TINEA  SYCOSIS 

Synonyms. — Tinea  trichophytina  barbae;  sycosis  parasitica;  bar- 
bers' itch;  ringworm  of  the  beard. 

Definition. — A  contagious,  parasitic  affection  of  the  hair,  hair- 
follicles,  and  subcutaneous  tissues  of  the  hairy  portion  of  the  face  and 
neck  in  the  adult  male,  due  to  the  trichophyton  fungus;  characterized 
by  the  development  of  tubercles  and  pustules. 

Causes. — -The  direct  cause  is  the  tricophyton  fungus.     Its  growth, 
is  no  doubt  aided  by  some  ill-defined  impairment  of  the  integument. 
The  affection  is  usually  acquired  in  the  barber  shop  but  may  be  con- 
tracted from  the  lower  animals,  especially  horses  and  cattle;  in  which 
cases  it  is  of  unusual  intensity. 

Pathology. — The  parasite  finds  its  way  into  the  hair-follicles  and 
attacks  the  root  and  shaft  of  the  hair,  causing  inflammation,  followed 
by  more  or  less  follicular  suppuration  and  general  infiltration  of  the 
surrounding  tissues.  The  presence  of  the  fungus  also  results  in 
inflammation  of  the  subcutaneous  connective  tissue  giving  rise  to  the 
well-known  tubercular  formations  peculiar  to  the  affection.  They 
are  firm,  comparatively  painless,  and  manifest  but  little  disposition 
to  undergo  change,  remaining  during  the  presence  of  the  fungus  and 
finally  disappearing  gradually  without  leaving  a  scar.  Under  the 
microscope  the  parasite  is  plainly  discernible. 

Sjnnptoms. — Barbers'  itch  begins  as  an  attack  of  tinea  circinata, 
with  one  or  more  reddish,  scaly  patches.  Soon  the  redness  and  des- 
quamation become  more  marked  and  swelling  and  induration  occur. 
With  the  advance  of  the  disease,  the  hairs  become  dry,  brittle,  and 
loose.  The  skin  soon  becomes  distinctly  nodular  and  lumpy,  and 
pustules  develop  about  the  openings  of  the  follicles.  The  subcuta- 
neous tissue  is  also  involved,  giving  rise  to  thick,  firm  masses  of  in- 
duration. The  affected  area  has  a  dark  red  or  purplish  color  and  is 
studded  with  a  large  number  of  tubercles  and  pustules.  Many  of  the 
pustules  discharge  a  purulent  material  which  accumulates,  forming 
crusts.  The  hairs  are  always  diseased  and  either  drop  out  or  break 
off  in  the  follicles  or  just  above  the  level  of  the  surface.-    The  chin, 


TINEA    SYCOSIS  713 

neck,  and  submaxillary  region  are  the  most  frequent  situations  of 
the  disease.  Itching,  burning,  and  pain,  of  varying  severity,  are 
always  present.  The  affection  is  extremely  chronic  and  relapses  are 
common. 

Diagnosis. — While  the  diagnosis  can  always  be  made  with  certainty 
by  the  aid  of  the  microscope,  the  affection  presents  certain  clinical 
characteristics  that  are  distinctive  in  very  many  cases. 

In  tinea  sycosis,  or  sycosis  parasitica,  the  skin  and  subacutaneous 
connective  tissue  are  extensively  involved,  as  manifested  by  the  in- 
duration and  formation  of  the  characteristic  tubercles.  The  upper 
lip  is  rarely  invaded;  the  hairs  are  diseased,  broken  off,  or  loose,  and 
under  the  microscope  reveal  the  parasite. 

Sycosis  nonparasitica  is  a  chronic,  inflammatory,  noncontagious 
affection  of  the  hair-follicles,  characterized  by  the  development  of 
papules  and  pustules  which  are  perforated  with  hairs,  the  hairs  them- 
selves being  unaffected.  The  upper  lip,  cheeks,  and  chin  are  the 
parts  mostly  involved.  If  of  long  duration,  some  inflammatory 
thickening  results. 

Pustular  eczema  may  resemble  tinea  sycosis,  with  extensive  pustu- 
lation  and  crusting;  but  in  the  former  the  hairs  are  not  involved,  nor 
are  the  characteristic  tubercles  present. 

Treatment. — The  following  plan  of  treatment  is  very  effective: 
Any  resisting  crusts  should  first  be  thoroughly  saturated  with  almond 
or  olive  oil  and  removed  by  washing  with  soft  soap  and  water.  The 
part  is  then  cleanly  shaved,  the  first  operation  being  more  painful 
than  subsequent  ones.  After  shaving,  the  face  is  bathed  in  water  as 
hot  as  can  be  borne.  All  pustules  should  then  be  opened  with  a  fine 
needle  and  the  parts  sponged  freely  with  a  solution  of  sodium  hypo- 
sulphite 3j  (4  gm.),  water  fBj  (30  c.c),  after  which  the  parts  are 
again  thoroughly  washed  with  hot  water,  carefully  dried,  and  sulphur 
ointment,  5  j  to  ij  (4  to  8  gm.)  to  the  ounce  (32  gm.),  applied.  This 
procedure  should  be  performed  preferably  at  night.  The  following 
morning  the  ointment  is  washed  off  with  soap  and  water,  the  face 
bathed  with  the  sodium  hyposulphite  solution,  and  dusted  with  any 
inert  powder.  This  plan  of  treatment  should  be  continued  regularly 
every  night,  omitting  the  shaving  when  the  beard  is  not  sufficiently 
long  enough  to  permit  it  without  great  distress.  In  very  obstinate 
cases  depilation  should  be  practised,  alternating  with  shaving.  The 
various  applications  recommended  in  the  treatment  of  tinea  tonsurans 
are  also  applicable  to  this  form  of  the  disease. 


714  '    TINEA  VERSICOLOR 

TINEA  VERSICOLOR 

Sjmonyms. — Pityriasis  versicolor;  liver-spots;  chromophytosis. 

Definition. — A  contagious  parasitic  affection  of  the  skin,  due  to 
the  microsporon  furfur,  characterized  by  the  occurrence  of  variously 
sized,  irregularly  shaped,  dry,  slightly  furfuraceous,  yellowish  spots 
upon  the  chest  or  other  portions  of  the  body. 

Cause. — Pityriasis  versicolor  is  the  result  of  the  presence  upon 
the  surface  of  the  skin  of  a  vegetable  fungus  termed  microsporon 
furfur.  It  is  a  mildly  contagious  affection  seen  after  puberty.  It  is 
said  to  occur  most  frequently  in  those  suffering  from  wasting  diseases, 
particularly  phthisis  pulmonalis.  It  is  not  connected  with  any 
affection  of  the  liver,  as  supposed  by  the  laity. 

Pathology. — The  fungus  permeates  the  horny  layer  of  the  epi- 
dermis, never  the  hairs  or  nails,  and  gives  rise  to  the  irregularly  shaped 
and  sized  macules  of  a  yellowish  or  brownish  color.  The  fungus 
consists  of  short,  jointed,  angular  mycelial  threads  and  rounded 
spores  more  or  less  grouped.  As  a  rule,  it  gives  rise  to  neither  hyper- 
emia nor  inflammatory  symptoms. 

Symptoms.^Tinea  versicolor  occurs  in  the  form  of  irregular, 
roundish,  circumscribed,  or  reticulated  macules.  The  spots  vary 
in  size  from  that  of  a  small  silver  coin  to  that  of  the  hand.  By 
coalescing  they  often  cover  a  greater  portion  of  the  chest,  their  most 
usual  site.  Upon  close  inspection  the  surface  of  the  macule  is  seen 
to  be  covered  with  furfuraceous  scales,  and,  if  the  scales  be  not 
visible,  scraping  with  the  finger-nail  will  demonstrate  their  presence. 
In  color  the  spots  vary  from  a  delicate  buff  or  fawn  shade  to  a  yellow- 
ish, deep  brown,  and,  rarely,  even  blackish  hue.  At  times  mild 
itching  accompanies  the  eruption.  The  affection  is  chronic  and  in 
the  absence  of  treatment,  persists  indefinitely.  Response  to  treat- 
ment, however,  is  prompt,  but  relapses  are  frequent,  due  in  all 
probability  to  a  failure  to  continue  treatment  for  a  sufficient  period. 

Diagnosis. — The  history,  course,  location,  and  character  of  the 
eruption  are  distinctive  enough  to  prevent  error,  but  in  doubtful 
cases  resort  should  be  made  to  the  microscope. 

Treatment. — The  parts  should  be  thoroughly  cleansed  with  soap 
and  water  and  either  of  the  following  lotions  applied. 

I^.     Sodii  hyposulphitis 5iij  12  gm. 

Glycerini f  5ij  8  gm. 

Aquae ad     §iv  ad     i2o  c.c. 

M,  S. — Apply  frequently. 


TINEA   FAVOSA  715 

Or— 

I^.     Hydrargyri  chlorid  corrosiv  gr.  iv  0.26  gm. 

Alcoholis f 5vj  23.0    c.c. 

Ammonii  chlorid 5ss  2.0    gm. 

Aquae  rosas ad  f  §  vj  178.0    c.c. 

M.  S. — Apply  frequently  (Tilbury  Fox). 

TINEA  FAVOSA 

Synonym. — Favus. 

Definition. — A  contagious  affection  of  the  skin,  due  to  a  vegetable 
parasite — Achorion  Schonleinii;  characterized  by  the  development 
of  either  discrete  or  confluent,  small  circular,  cup-shaped,  pale- 
yellow,  friable  crusts,  usually  perforated  by  hairs. 

Cause. — The  presence  and  growth  of  a  vegetable  parasite  known 
as  the  Achorion  Schonleinii  is  the  cause  of  tinea  favosa.  It  is  more 
common  in  children  than  in  adults,  attacking  the  former  in  the 
first  place  either  de  novo  or  through  direct  contagion,  and  is  from 
them  communicated  to  adults.  The  affection  is  often  contracted 
from  the  lower  animals.  It  is  a  disease  confined  almost  exclusively 
to  the  lower  classes,  especially,  of  Russians,  Polish,  Austrians,  and 
Hungarians. 

Pathology. — Tinea  favosa  may  have  its  seat  either  in  the  hair- 
follicles  and  hair,  or  upon  the  surface  of  the  skin  or  the  nails ;  the  former, 
however,  being  the  structures  most  frequently  involved.  The  crusts 
are  made  up  almost  entirely  of  fungus,  which  upon  section  is  seen 
with  the  naked  eye  to  be  composed  of  a  porous  mass  and  to  possess 
a  pale-yellow  or  whitish  color.  Under  the  microscope  it  is  seen  to 
consist  of  both  mycelium  and  spores  in  great  quantity  and  in  all 
stages  of  development. 

Sjrmptoms. — When  the  affection  attacks  the  hairs  and  follicles 
it  is  termed  tinea  favosa  pilaris;  when  the  epidermis,  tinea  favosa  epi- 
dermidis;  and  when  the  nails,  tinea  favosa  unguium.  Rarely  all  the 
structures  may  be  attacked  at  one  and  the  same  time ;  its  usual  seat, 
however,  is  the  scalp.  The  disease  begins  by  the  development  of 
one  or  of  several  pin-head  sized,  pale-yellow  crusts,  seated  about  the 
hair-follicles.  In  about  a  fortnight  these  crusts  have  increased  in 
size  and  are  umbilicated,  favus  cups,  circumscribed,  cirular  in  form, 
friable,  and  very  slightly  elevated  above  the  level  of  the  skin.  Or- 
dinarily, they  are  of  a  pale-yellow  or  sulphur-yellow  color,  but  after 
a  time,  from  dust  and  other  matters,  they  become  brQwnish^or  green- 


7l6  '         TINEA  FAVOSA 

ish  yellow  in  color.  The  number  of  crusts  varies  from  very  few  to 
immense  numbers.  The  usual  size  is  about  that  of  a  split  pea. 
In  tinea  favosa  pilaris  et  capitis  the  affection  is  often  accompanied 
by  pediculi,  while  swelling  of  the  glands  of  the  neck  and  small 
abscesses  upon  the  scalp  are  not  uncommon.  The  hairs  become 
lusterless,  opaque,  brittle,  and  at  times  split  longitudinally,  and  from 
atrophy  of  the  follicles  and  sebaceous  glands  and  scarring,  permanent 
baldness  may  result. 

The  lesions  have  a  peculiar  odor,  resembling  that  of  mice,  or  of 
musty,  stale  straw. 

In  tinea  favosa  unguium  the  nails  become  thickened,  yellow,  opaque, 
and  brittle. 

Diagnosis. — The  distinctive  features  of  this  disease  that  will  serve 
to  differentiate  it  from  other  affections  of  the  scalp  are  its  history, 
long  duration,  the  sulphur-yellow,  umbilicated,  crusts,  the  peculiar 
odor,  the  atrophic  scarring,  and  the  presence  of  the  fungus  which  may 
be  readily  detected  by  microscopic  examination. 

Prognosis. — Tinea  favosa  of  the  epidermis  readily  responds  to 
treatment.  Tinea  favosa  pilaris  is  more  obstinate,  and  if  of.  long 
duration,  may  result  in  baldness. 

Treatment. — Many  of  the  patients  are  in  comparatively  poor 
health  and  require  general  tonic  treatment.  Attention  to  personal 
hygiene  and  cleanliness  should  not  be  neglected.  The  local  treat- 
ment is  of  great  importance  and  consists  essentially  in  depilation  and 
the  application  of  parasiticides.  The  hair  should  be  cut  off  as  short 
as  possible,  the  crusts  removed  by  the  use  of  oil,  or  soap  and  hot 
water,  or  poultices,  again  well  oiled,  and  the  hairs  removed  by  means 
of  broad-bladed  forceps,  a  few  hairs  being  removed  at  a  time  and  only 
a  small  surface  cleared  at  each  sitting,  after  which  the  following  lotion 
is  to  be  thoroughly  applied: 

I^.      Hydrarg.  chlorid.  corrosiv.    gr.  v  to  x  0.3  to  0.6  gm. 

Ammonii  chlorid 5  ss  2.0  gm. 

Misturas  amygdalae  amar.  .   fgiv       120.0  c.c. 

M.  S. — Apply  thoroughly  (Bulkley). 

Stelwagon  employs  the  following: 

I^.     Acid,  carbol 5j  4  gm. 

Ung.  picis.  liq., 

Ung.  hydrarg.  nitrat.  .  .  .aa  5ij  8  gm. 

Ung.  sulphur 5iv  16  gm. 

M.  S. — Apply  locally. 


SCAEIES  717 

Owing  to  the  decomposition  likely  to  occur  in  this  prepara- 
tion it  vshould  be  prepared  freshly  or  within  a  week  of  its  being 
employed. 

Other,  parasiticides  may  also  be  employed,  the  keynote  to  success 
in  their  use  is  -regular  vigorous  application  continued  over  a  long 
period.  No  case  should  be  discharged  until  the  microscope  is  no 
longer  able  to  reveal  the  fungus.  The  a; -ray  has  been  used  with 
marked  success  by  Sabouraud  of  Paris,  and  others. 

When  the  nails  are  affected  they  should  be  scraped  in  addition  to 
the  local  applications. 

SCABIES 

Synonym. — The  itch. 

Definition. — A  contagious  animal  parasitic  disease  of  the  skin,  due 
to  the  acarus,  or  sarcoptes  scahiei;  characterized  by  the  formation  of 
cuniculi  (burrows),  papules,  vesicles,  pustules;  followed  by  excoria- 
tions, crusts,  and  general  cutaneous  inflammation,  and  accompanied 
by  itching. 

Causes. — The  essential  cause  is  the  animal  parasite,  acarus  or 
sarcoptes  scahiei.  The  affection  is  contagious  and  attacks  individuals 
at  all  ages  and  in  every  walk  of  life.  It  may 
be  contracted  by  direct  contact  with  in- 
fected persons  or  through  the  medium  of 
bedclothes  and  similar  articles.  It  is  most 
frequent  where  there  are  large  bodies  of 
people  congregated  together  under  unhy- 
gienic  conditions,  as   in  camps,  barracks, 

ships, 'tenement  houses,  etc.  Fig.  61.— Sarcoptes  scabiei. 

Pathology. Scabies    is    an    inflammation     (Braun.).      {Greene's    Medical 

of  the  skin  with  the  development  of  papules,      ^"■snosts. 
vesicles,  pustules,  excoriations,  and  subsequent  crusting,  the  result 
of  the  ravages  of  the  animal  parasite,  together  with  the  irritation 
produced  by  the  scratching  of  the  patient. 

The  parasite  acarus,  or  sarcoptes  scabiei,  is  a  minute  creature, 
barely  visible  to  the  naked  eye,  appearing  as  a  yellowish- white,  rounded 
body.  The  female  is  the  most  commonly  encountered;  the  males 
are  said  to  take  no  part  in  causing  the  afiEection  and  are  rarely  seen. 
They  are  said  to  die  in  about  a  week  after  copulation  with  the  female. 
The  female  finds  her  way  boring  through  the  horny  layer  into  the 


7l8  •  SCABIES 

mucous  layer  of  the  epidermis,  and,  being  impregnated,  begins  at 
once  laying  her  eggs  and  at  the  same  time  miaking  her  burrow.  A 
variable  number  of  eggs  is  deposited,  usually  about  a  dozen,  after 
which  she  perishes  in  the  skin.     The  ova  hatch  out  in  six  or  ten  days. 

S3miptoms. — The  eruption  of  scabies  is  an  artificial  dermatitis  or 
eczema,  according  to  the  amount  of  irritation  produced  by  the  pres- 
ence of  the  parasite  and  the  traumatism  resulting  from  the  severe 
scratching  of  the  patient. 

Immediately  upon  the  arrival  of  the  itch-mite  upon  the  skin  it 
begins  its  work  of  burrowing,  and  very  soon  a  burrow,  or  cuniculus, 
is  formed,  in  which  the  eggs  are  deposited,  and  which  also  becomes  the 
habitat  of  the  female  during  the  remainder  of  her  life.  The  ova  are 
hatched  in  about  one  week  after  their  deposit,  and  at  once  begin  to 
care  for  themselves  and  to  burrow,  resulting  in  the  formation  of  as 
many  additional  cuniculi  as  there  are  active  female  mites.  It  is  the 
presence  of  these  burrowing  parasites  that  constitutes  the  irritation 
resulting  in  the  inflammation  of  the  skin,  characterized  by  the  forma- 
tion of  minute  papules,  vesicles,  and  pustules,  with  more  or  less  in- 
flammatory induration.  Add  to  these  the  excoriations,  scratch 
marks,  fissures,  torn  vesicles,  and  pustules  with  yellow  and  bloody 
crusts,  caused  by  the  scratching,  and  a  picture  of  the  fully  developed 
disease  is  seen. 

The  burrow,  or  cuniculus,  as  it  is  termed,  is  formed  by  the  mite 
entering  and  making  its  way  beneath  the  horny  layer  of  the  epidermis, 
which  is  raised,  very  much  as  a  mole  undermines  the  ground.  It 
occurs  as  a  slight  linear  elevation  of  the  epidermis  varying  from  a 
half  a  line  to  four  or  five  lines  in  length,  and  having  an  irregular  or 
tortuous  course.  Its  color  is  whitish  or  yellowish,  speckled  here  and 
there  with  dark  dots.  At  either  end  the  cuniculus  terminates  as 
darkish  points,  the  more  prominent  of  which  represents  the 
parasite. 

The  papules  are  the  first  inflammatory  lesion;  they  are  numerous 
and  of  small  size,  and  may  be  the  extent  of  the  disease.  The  vesicles 
are  the  next  stage,  varying  in  size  and  number,  having  an  inflamed 
base,  sometimes  presenting  cuniculi  upon  their  summits.  The  pus- 
tules represent  the  completion  of  the  inflammatory  action,  their  size 
and  number  varying  with  the  severity  of  the  irritation. 

The  intense  itching  which  is  worse  at  night,  results  in  excoriations, 
torn  papules,  vesicles,  and  pustules,  followed  by  crustings,  which 
after  a  time  disguise  the  characteristic  lesions.     The  regions  of  the 


SCABIES  '     ,  719 

body  attacked  by  the  parasite  are  the  hands,  especially  the  sides  of 
the  fingers  and  the  folds  where  they  join  the  hands.  After  a  time 
the  wrists,  penis,  and  mammae,  and  around  about  and  upon  the  nipples, 
are  invaded.  The  resultant  multiform  eruption  is  usually  found  in 
the  various  flexor  regions  of  the  body,  inner  sides  of  the  thighs,  and 
the  buttocks,  but  may  be  general.  The  face  is  free  from  the  disease 
except  occasionally  in  nursing  infants.  In  very  clean  persons,  or 
those  having  their  hands  constantly  in  water,  there  may  be  no  bur- 
rows or  other  lesions  on  the  hands. 

Diagnosis. — The  presence  of  the  itch-mite  and  its  burrows  is 
pathognomonic.  A  multiform  eruption  most  marked  in  the  flexor 
regions  with  intense  itching,  worse  at  night,  and  a  history  of  contagion 
are  also  diagnostic  of  the  disease.  Frequently  the  burrows  are 
removed  by  scratching  and  a  careful  search  fails  to  detect  any  of 
them. 

Prognosis. — The  disease  never  tends  toward  spontaneous  cure. 
When  severe,  a  diffuse  eczema  may  be  engrafted  on  the  original 
condition.  Under  appropriate  .treatment  response  is  prompt  and 
cure  is  rapid. 

Treatment.— In  every  instance,  all  members  of  the  household 
having  the  affection  should  be  treated  at  the  same  time.  The  bed- 
clothing  and  underclothing  of  infected  individuals  should  be  steril- 
ized. Patients  under  treatment  should  sleep  alone  for  obvious 
reasons.  The  treatment  should  be  directed  first  toward  the  scabies, 
after  which  the  attendant  dermatitis  should  receive  attention. 
The  following  plan  of  treatment  is  very  satisfactory:  An  ointment 
such  as — 

I^.     Sulph.  pragcip 5j  4  gm. 

Petrolat §j  32  gm. 

M.  S. — Apply  locally  at  night. 

should  be  applied  all  over  the  body  from  the  neck  to  the  soles  of  the 
feet  for  four  nights,  after  which  a  hot  bath  is  taken  and  the  bedclothes 
and  underclothes  are  changed.  The  treatment  is  then  withheld 
for  an  equal  period  to  allow  the  irritation  to  subside.  If  after  this 
period  elapses  the  generalized  itching  returns,  the  ointment  is  again 
applied  in  a  similar  manner  for  three  or  four  days.  At  the  end  of 
this  time,  only  a  few  localized  areas  of  itching  will  remain,  which  will 
also  disappear  with  the  application  of  a  weak  carbolic-acid  lotion 
or  ointment  (gr.  v  to  x  to  the  ounce). 


720  *  PEDICULOSIS 

Another  valuable  method  of  treatment  consists  in  the  patient 
first  washing  himself  thoroughly  with  soft  soap  and  water,  after 
a  warm  bath  is  taken.  Tincture  of  benzoin  or  one  of  the  following 
is  then  applied  all  over  the  body  twice  daily  except  the  head 
and  face : 

I^.     Sulph.  praecip., 

Betanaphthol aa   5ss  2.0  gm. 

Petrolat §  j  32.0  gm. 

M.  S. — Apply  locally. 

I^.     Styracis  liquid f  3ij  8 -O  gm. 

Ung.  sulphur 5ij  to  iv  8    to  16.0  gm. 

Petrolat q.  s.  ad   §  j  32.0  gm. 

M.  S. — Apply  after  washing  (Bulkley). 

I^.     Sulph.  praecip 5j  4-0  gm. 

Balsam.  Peruviani 5ss  2.0  gm. 

Adipis ; Bj  •32.ogm. 

M.  S. — For  children  (Duhring). 

I^.     Creolin gr.  v  o .  32  gm. 

Petrolat §  j  32.0    gm. 

M.  S. — Apply  locally. 

In  children,  the  strength  of  all  remedies  employed  for  this  purpose 
should  be  reduced  to  prevent  undue  irritation.  Styrax  and  balsam 
of  Peru  are  most  useful  in  infantile  cases.  In  using  betanaphthol, 
its  stinging  properties  when  first  applied  should  be  borne  in  mind. 
Apart  from  this,  it  is  perhaps  the  most  elegant  of  all  these  prepara- 
tions. Care  should  always  be  taken  not  to  continue  the  treatment 
for  too  long  a  period  at  a  time. 

PEDICULOSIS 

Synonyms. — Phthiriasis;  lousiness. 

Definition. — A  contagious,  animal  parasitic  disease  of  the  head, 
body,  or  pubes,  due  to  the  presence  of  pediculi  and  characterized 
by  the  wounds  inflicted  by  the  parasite,  together  with  excoriations 
and  scratch  marks. 

Varieties. — Pediculosis  capitis;  pediculosis  corporis;  pediculosis 
pubis. 

Pathology. — The  lesion  produced  by  the  presence  of  the  pediculi 


PEDICULOSIS 


721 


^Ik 

f 

MM 

F 

Fig.  62. — Pediculus 
Capitis  and  egg.  {Greene's 
Medical  Diagnosis.) 


is  a  minute  hemorrhage,  caused  by  the  parasite  inserting  its  sucking 
apparatus,  or,  as  it  is  termed,  its  haustellum,  into  a  follicle,  and  ob- 
taining blood  by  a  process  of  sucking,  and  not  by  biting  as  is  generally 
supposed.  The  presence  of  the  parasite  in  any  great  numbers  brings 
about  a  peculiar  irritable  state  of  the  skin,  which  gives  rise  to  an  irre- 
sistible desire  to  scratch,  as  a  consequence  of 
which  the  surface  is  markedly  excoriated. 

Symptoms. — The  symptoms  which  arise  from 
the  presence  of  the  parasite  in  different  locali- 
ties are  somewhat  different,  and  call  for  separate 
consideration. 

Pediculosis  Capitis. — This  variety  is  caused 
by  the  presence  of  the  pediculus  capitis,  or  head- 
louse.  The  ova,  or  nits,  are  readily  recognized 
at  a  distance.  Their  favorite  seat  is  the  occip- 
ital region,  either  upon  the  surface  of  the 
scalp  or  upon  the  hair.  Their  presence  gives  rise  to  considerable 
irritation,  itching,  and  consequent  scratching,  resulting  in  the 
wounding  of  the  scalp,  with  oozing  of  a  serous  or  purulent  fluid 
mixed  with  blood,  which  soon  mats  the  hair  and  forms  into  crusts. 
In  those  predisposed  to  eczema  the  presence  of  the  -  parasite  will 
give  rise  to  that  condition. 

Pediculosis  Corporis. — This  variety  of  the  pediculosis  is  caused 
by  the  presence  of  the  pediculus  corporis,  or  body-louse,  or  more 
properly  termed  the  pediculus  vestimenti,  or  clothes-louse.  Its 
color,  when  devoid  of  blood,  is  dirty- white  or  grayish,  with  a  dark  line 
around  the  margin  of  its  abdomen.  Its  habitat  is  the  clothing  cover- 
ing the  general  surface,  remaining  upon  the  skin  only  long  enough 
to  obtain  sustenance.  The  ova  are  usually  deposited  in  the  seams 
of  the  clothing,  the  lice  being  hatched  within  a  week.  Occasionally 
a  few  of  the  pediculi  may  be  observed  crawling  about  the  surface,  or 
in  the  act  of  drawing  blood.  As  they  move  over  the  surface,  they 
give  rise  to  an  intensely  disagreeable  itching  sensation,  to  relieve 
which  the  patient  scratches,  which  in  turn  gives  rise  to  the  charac- 
teristic lesions  of  the  affection. 

The  lesions  are  numerous.  The  scratch  marks  are  scattered  here 
and  there,  either  long  and  streaked,  in  other  places  short  and  jagged, 
the  excoriations  and  blood-crusts  varying  in  size  from  a  pin-head  to  a 
split  pea  or  even  larger,  with  irregularly  shaped  pustules.  In  addi- 
tion to  the  lesions  resulting  from  the  scratching  are  seen  the  primary 
46 


722  -•         iP.EDlCtJLOSiS 

lesions,  consisting  of  minute,  reddish  puncta  with  slight  areolae,  the 
points  at  which  the  parasite  has  drawn  blood.     In  cases  of  long  stand- 
ing a  brownish  pigmentation  of  the  whole  skin  may  result  from  the 
long-continued    irritation    and    scratching.     The 
favorite  sites  of  the  lesions  are  the  back,  especially 
about  the  scapular  region,   the  chest,   abdomen, 
hips,  and  thighs.     Pediculosis  is  seen  most  com- 
monly among  the   poorer   classes,  and  especially 
the  middle-aged  and  elderly. 
Fig.  63. — Pedicu-        Pediculosis  Pubis. — This  variety  of  pediculosis 

lus  Pubis.     (Greene's      •  j    i.       j.i_  r  x-u  j-       1  t,* 

Medical  Diagnosis.)  IS  caused  by  the  presence  of  the  pediculus  pubis, 
or  crab-louse.  Although  having  its  seat  of  predi- 
lection about  the  pubes,  it  may  also  infest  the  axillae,  sternal  region  in 
the  male,  beard,  eyebrows,  and  even  the  eyelashes. 

They  may  be  found  crawling  about  the  hairs,  but  more  commonly 
hugging  the  surface  closely.  They  infest  adults  chiefly  and  occasion 
symptoms  similar  to  those  described  in  connection  with  the  other 
varieties.  They  are  usually  contracted  through  sexual  intercourse, 
although  occasionally  they  are  present  in  cases  in  which  they  have 
not  been  communicated  in  this  way,  and  in  which  no  explanation  as 
to  the  mode  of  contagion  can  be  suggested.  The  itching  varies  from 
slight  to  severe. 

Diagnosis. — When  violent  itching  exists  in  any  case,  without  a 
well  defined  eruption,  the  possibility  of  the  presence  of  pediculi 
should  always  be  entertained,  and  if  carefully  sought  after,  are  usually 
found. 

Prognosis. — Favorable,  if  the  treatment  be  thoroughly  carried  out. 

Treatment.  Pediculosis  Capitis. — The  most  effective  application 
to  this  variety  is  to  thoroughly  soak  the  head  two  or  three  times  a  day 
with  ordinary  petroleum  or  kerosene  oil  and  keep  it  wrapped  in  a 
cloth  for  twenty-four  hours.  At  the  end  of  this  time  the  head  should 
be  thoroughly  washed  with  soft  soap  and  hot  water,  dried,  and  satu- 
rated with  the  official  ointment  of  ammoniated  mercury.  If  required, 
this  entire  procedure  may  be  repeated,  but  usually  any  pediculi 
escaping  the  petroleum  are  destroyed  by  the  ointment. 

Pediculosis  Corporis. — In  this  variety  the  habitat  of  the  parasite 
being  the  clothes,  they  must  be  boiled  or  baked  at  a  temperature 
sufficiently  high  to  destroy  the  pediculi.  After  this  the  clothing  should 
be  changed  every  day  or  two,  carefully  inspected,  and  if  pediculi  are 
seen,  the  clothes  must  again  be  baked  or  boiled.     For  the  irritation, 


LENTIGO  723 

itching,  and  excoriations,  mild  alkaline  baths  or  lotions  of  carbolic 
acid  are  sufficient. 

Pediculosis  Pubis. — The  parts  should  be  washed  twice  daily  with 
soft  soap  and  water,  after  which  the  thorough  application  of  tincture 
of  cocculus  indicus  (fish  berries),  full  strength  or  diluted,  dried,  and 
saturated  with  the  official  ointment  of  ammoniated  mercury,  or 
mercurial  ointment  (blue  ointment),  will  be  effectual.  Fluidextract 
of  staphisagria  is  an  excellent  application: 

I^.     Pluidext.  staphisagriae .  .  .   f  oiv  16  c.c. 

Acidi  acetici  dil f5vj  180  c.c. — M. 


HYPERTROPHIES  OF  THE  SKIN 

LENTIGO 

Synonym. — Freckles. 

Definition. — A  pigmentary  deposit  of  the  skin,  characterized  by 
irregularly  shaped,  pin-head  or  pea-sized,  yellowish,  brownish,  or 
blackish  spots  occurring  for  the  most  part  about  the  face  and  back 
of  the  hands. 

Cause. — In  the  majority  of  instances  exposure  to  the  sun  is  the 
exciting  cause. 

Pathology. — In  the  anatomic  structure  freckles  cpnsist  of  a  circum- 
scribed, increased  amount  of  normal  pigment,  differing  from  chloasma 
only  in  the  peculiar  form  and  size  of  the  deposit. 

Symptoms. — The  number  of  ''freckles"  varies  from  a  very  few  to 
immense  numbers.  They  occur  as  brownish  or  yellowish-brown, 
small,  roundish,  irregular  spots,  most  commonly  upon  the  face  and 
hands.  Rarely  the  number  is  very  great,  and  they  give  to  the  skin 
an  uncleanly  appearance.  They  are  apt  to  occur  at  all  ages,  but 
rarely  before  the  third  year.  They  aye  unattended  with  itching  or 
other  subjective  symptoms. 

Prognosis. — Usually  favorable.  Their  course,  when  left  to  them- 
selves, is  chronic,  lasting  for  years  or  a  life-time.  They  ordinarily 
appear  in  the  summer,  fading  away  as  cold  weather  approaches,  to 
return  the  following  summer. 

Treatment. — The  following  application  has  usually  been 
successful: 


724  CHLOASME 

IJ.     Hydrargyri  chlor.  corrosiv .   gr.  iij  0.2  gm. 

Acid,  hydrochlorici  dil f  3j  4.0  c.c. 

Alcoholis f 5j  30.0  c.c. 

Glycerini fgss  15.0  c.c. 

Aquae  rosse q.  s.  ad  f  5iv  ad  120.0  c.c. 

M.  S. — Apply  at  bedtime,  and  remove  with  soap  and  water 
in  the  morning. 

CHLOASMA 

Synon3rms. — ^Liver  spots;  moth. 

Definition. — A  pigmentary  disturbance  of  the  skin,  characterized 
by  variously  sized  and  shaped,  more  or  less  defined,  smooth  patches, 
of  a  yellowish,  brownish,  or  blackish  color. 

Cause. — The  affection  may  be  idiopathic  or  symptomatic. 

Idiopathic  chloasma  results  from  the  irritation  of  long-continued 
scratching,  such  as  occurs  in  severe  eczema  or  pediculosis,  the  applica- 
tion of  bHsters  and  sinapisms,  heat,  the  direct  rays  of  the  sun,  and 
various  medicinal  and  chemical  substances. 

Symptomatic  chloasma  occurs  in  connection  with  cancer,  malaria, 
tuberculosis,  disease  of  the  suprarenal  capsule  (Addison's  disease), 
disease  of  the  uterus,  pregnancy  (chloasma  uterinum),  neurotic 
disturbances,  dementia,  anemia,  and  chlorosis. 

Pathology. — The  affection  consists  of  an  increased  deposit  of  the 
normal  pigment  in  the  mucous  layer  of  the  epidermis.  The  deposi- 
tion of  the  additional  pigment  is  the  result  of  a  nervous  derangement, 
possibly  of  the  trophic  system. 

Symptoms. — Chloasma  is  simply  a  discoloration  of  the  skin, 
unattended  by  any  alteration  of  the  surface.  The  patches  vary 
in  size  and  shape;  they  may  be  as  small  as  a  coin  or  as  large  as  the 
hand,  or  much  larger,  even  to  a  universal  discoloration  of  the  entire 
surface,  and  they  may  be  roundish  or  irregular  in  outline.  The  usual 
color  is  yellowish,  brownish,  or  muddy,  or  even  blackish  {melasma, 
melano-derma) . 

In  Addison's  disease,  of  a  typical  character,  the  coloration  is 
brownish,  with  an  olive-greenish  or  bronze  tint,  and  is  general, 
although,  as  a  rule,  especially  pronounced  upon  regions  having  a 
disposition  to  normal  increase  of  pigment,  as  the  face,  backs  of  the 
hands,  axillae,  areolae  of  the  nipples,  and  the  genital  organs;  the  hair, 
also,  may  become  darkened. 

In  argyria,  or  discoloration  of  the  skin  resulting  from  the  internal 


CHLOASMA  725 

use  of  nitrate  of  silver  over  a  long  period,  the  color  is  a  bluish  gray, 
slate,  bronze,  or  blackish,  varying  as  to  the  shade.  It  occurs  over 
the  surface  generally,  but  is  more  pronounced  upon  parts  exposed, 
as  the  face  and  hands. 

Chloasma  uterinum  occurs  most  frequently  between  the  ages  of 
twenty-five  and  fifty,  seldom  after  the  menopause,  and  is  caused, 
in  the  greater  number  of  instances,  by  changes,  physiological  and 
pathological,  which  take  place  in  connection  with  the  uterus.  It  is 
seen  in  the  married  and  single,  although  more  common  in  the  former. 
Pregnancy  is  the  most  frequent  cause,  but  it  is  also  associated  with 
either  dysmenorrhea,  chlorosis,  anemia,  or  hysteria.  It  is  seen 
in  the  mildest  degree  about  the  eyelids,  especially  during  the  men- 
strual epoch,  as  a  duskiness  or  swarthiness  of  the  complexion,  either 
lasting  a  few  days  or  being  permanent.  As  usually  encountered, 
however,  chloasma  of  this  variety  consists  in  the  presence  of  one  or 
several  patches,  appearing  generally  about  the  forehead  or  other 
parts  of  the  face,  upon  the  trunk,  about  the  nipples,  and  upon  the 
abdomen.  Rarely,  the  entire  face  is  covered  with  a  discoloration, 
resembling  a  mask.  Cases  are  recorded  in  which  the  pigmentary 
deposit  was  general,  resembling  Addison's  disease. 

Diagnosis. — Tinea  versicolor  and  chloasma  resemble  each  other 
in  the  color  of  the  patches,  but  otherwise  they  have  nothing  in  com- 
mon. Tinea  versicolor  occurs  on  the  trunk,  while  chloasma  occurs 
upon  the  face  and  about  the  nipples,  and  in  cases  the  result  of  preg- 
nancy about  the  umbilicus,  except  in  those  comparatively  rare  in- 
stances in  which  the  discoloration  is  diffused.  The  patches  of  chlo- 
asma are  smooth,  those  of  tinea  versicolor  furfuraceous,  as  can  readily 
be  demonstrated  by  gently  scraping  the  discoloration  with  the 
finger-nail.     The  parasite  is  absent  in  chloasma. 

Prognosis. — The  outlook  is  favorable  except  in  cases  due  to  the 
prolonged  use  of  silver  nitrate,  Addison's  disease,  tuberculosis, 
or  cancer. 

Treatment. — Except  when  due  to  organic  disease  or  silver  deposits 
in  the  skin,^the  pigmented  areas  may  be  temporarily  removed  by 
one  of  the  following: 

I^.     Hydrargyri     chloridi     cor- 

rosiv gr.  vijss  o .  5  gm. 

Zinci  sulphat 5ss  2.0  gm. 

Plumbi  acetatis 5ss  2.0  gm. 

Aquae fBiv  120.0  c.c. 

M.  S. — ^Lotion.     Apply  morning  and  evening  (Hardy). 


726  CALLOSITAS 

Or— 

I^      Hydrargyri     chloridi     cor- 

rosiv gr.  vj  0.4  gm. 

Acidi  acetici  dil f  5ij  8.0  c.c. 

Boracis gr.  xl  2.6  gm. 

Aquae  rosae f  §iv  120.0  c.c. 

M.  S. — Lotion.     Apply  twice  daily  (Bulkley). 

I^.     Hydrarg.  ammoniat 3j  4-0  gm. 

Bismuthi  subnit 5j  4-0  gm. 

Petrolat 5  j  32 .  o  gm. 

M.  S. — Apply  frequently. 

CALLOSITAS 

Synonyms. — Tyloma;  callus;  callosity. 

Definition. — Callositas  consists  in  the  development  of  a  hard 
or  horny,  thickened  patch  of  skin,  variable  in  extent,  of  a  grayish, 
yellowish,  or  brownish  color,  and  unattended  by  pain.  The  most 
frequent  location  is  upon  the  hands  and  feet. 

Causes.- — The  principal  cause  is  local  pressure  or  friction,  as  in  the 
case  of  the  hands  of  the  mechanic,  the  effect  of  his  tools;  or,  if  upon 
the  foot,  the  result  of  ill-fitting  shoes  or  from  long  marches.  Cal- 
losities are  also  seen  upon  the  fingers  of  violin,  banjo,  and  harp  players. 

Pathology. — Hypertrophy  of  the  horny  layer  of  the  skin  is  present, 
the  corium  remaining  normal.  The  cells  of  the  epidermis  become 
so  closely  packed   together  as  often  to  simulate    horn-substance. 

Symptoms. — Callositas  consists  in  an  increase  in  the  thickness 
of  the  skin  of  the  affected  part,  presenting  a  firm,  dense,  more  or  less 
circumscribed  structure,  the  extent  of  hardness  varying  considerably. 
The  patch  of  hardness  is  generally  about  the  size  of  a  coin,  roundish 
in  shape,  and  somewhat  elevated  above  the  surrounding  skin.  The 
color  may  be  either  grayish,  yellowish,  or  brownish. 

Callosities  are  usually  situated  upon  the  palms,  fingers,  soles, 
and  toes,  although  other  parts,  if  exposed  to  the  cause,  may  also  be 
the  seat.  At  times  great  pain  and  discomfort  are  experienced  from 
the  growth. 

Occasionally  callosities  are  complicated  by  hyperemia,  fissures, 
acute  inflammation,  abscess,  erysipelas,  and  serve  readily  as  foci 
for  such  cutaneous  diseases  as  eczema  and  psoriasis.  Their  forma- 
tion and  development  is  always  slow  and  gradual.  If  the  cause 
be  removed,  the  prognosis  is  favorable. 


CLAVUS  727 

Treatment. — If  the  removal  of  the  callous  growth  be  desirable,  the 
part  should  be  repeatedly  soaked  in  warm  water,  or  a  poultice  applied, 
or  warmed  oil  kept  in  contact  by  compresses  of  flannel,  which  will 
soften  the  induration  and  permit  its  removal  by  paring  or  scraping, 
layer  by  layer,  with  a  sharp  knife.  Success  has  been  obtained  from 
the  use  of  a  plaster  of  india-rubber  containing  salicylic  acid.  Paint- 
ing with  diluted  tincture  of  iodine  once  daily  is  often  serviceable. 

CLAVUS 

Synonym. — Corn. 

Definition. — A  corn  is  a  small,  circumscribed,  usually  flat,  deep- 
seated  hypertrophy  of  the  epidermis,  having  a  horny  feel,  projecting 
slightly  from  the  skin,  painful  upon  pressure,  and  situated  for  the 
most  part  about  the  toes. 

Causes. — Continual  pressure  or  friction,  usually  from  ill-fitting  or 
tight  boots  or  shoes. 

Pathology. — A  clavus  consists  of  a  circumscribed,  excessive  hyper- 
trophy of  the  epidermis,  of  the  same  character  as  occurs  in  callosity, 
and  of  a  central  portion — the  core.  The  core  extends  deeply  into  the 
tissues,  in  the  shape  of  an  inverted  cone,  the  base  of  the  cone  being 
directed  outward  and  appearing  upon  the  surface  as  a  roundish  eleva- 
tion, its  apex  resting  upon  the  papillary  layer  of  the  corium.  The 
core  of  a  clavus  consists  of  a  whitish,  opaque,  firm,  tenacious  body, 
composed  of  epidermic  cells,  arranged  in  concentric  laminae. 

The  pain  attending  the  presence  of  corns  results  from  pressure  upon 
the  true  skin  by  the  hard  core,  causing  irritation  of  the  nerve-fila- 
ments of  the  papillae. 

Corns  existing  between  two  toes  are  constantly  bathed  with  the 
moisture  of  the  part,  which  macerates  and  softens  the  formation, 
which  thus  receives  the  name  of  soft  corn,  in  contradistinction  to 
the  hard  corn. 

Symptoms. — Until  the  growth  attains  a  considerable  size  no  dis- 
comfort, as  a  rule,  is  felt.  After,  however,  its  depth  has  reached  the 
true  skin,  pain  of  an  intermittent  character,  aggravated  by  pressure, 
is  the  chief  symptom.  Corns  are  often  weather  sensitive,  being 
unusually  painful  before,  during,  or  after  the  occurrence  of  storms, 
and  should,  therefore,  not  be  confounded  with  gouty  or  rheumatic 
deposits  below  the  skin. 

Treatment.^If  freedom  from  these  annoying  formations  be  desired 


728  ICHTHYOSIS 

a  properly  fitting  foot-covering  must  be  worn.  The  pressure  which 
results  in  the  severe  pain  is  limited  by  the  use  of  the  ringed  protective 
plasters  in  common  use. 

To  remove  the  corn,  soaking  with  hot  water,  or  a  poultice  kept  in 
contact  over  night,  will  soften  the  part  and  permit  of  its  ready 
removal  with  the  knife. 

The  following  application  will' usually  remove  the  "com:" 

I^.     Acidi  salicylici 3  jss  6 .  o  gm. 

Ext.  cannab.  indicse gr.  x  0.6  gm. 

CoUodii f  5j  30.0  CO. 

M.   S. — To  be  painted  over  the  corn  at  night  and  scraped 
off  in  the  morning. 

For  soft  corns,  the  application  of  silver  nitrate  in  solid  stick  form 
is  highly  spoken  of,  to  be  used  after  the  growth  has  been  sujfficiently 
softened. 

ICHTHYOSIS 

Synonyms. — Ichthyosis  vera;  fish-skin  disease. 

Definition. — Ichthyosis  is  a  congenital,  chronic  deformity  or  hyper- 
trophic disease  of  the  skin,  characterized  by  dryness,  harshness,  or 
general  scaliness  of  the  skin,  or  in  the  outgrowth  of  larger  masses  of  a 
corneous  consistency. 

Varieties. — Ichthyosis  simplex;  ichthyosis  hystrix. 

Cause. — It  is  to  be  regarded  as  an  affection  which  is  born  with  the 
individual,  although  it  does  not  usually  manifest  itself  until  after  the 
first  or  second  year  of  life.     It  is  often  hereditary. 

Pathology. — "The  diseased  or,  better,  deformed  skin  is  found  mi- 
croscopically to  be  hypertrophied  in  various  degrees,  according  to  the 
development  of  the  malady ;  the  proliferation  of  its  elements  occurring 
in  the  connective  tissue,  papillae,  stratum  comeum,  and  blood-vessels. 
In  well-marked  cases  of  ichthyosis  hystrix  the  elongated  papillae  are 
surrounded  by  dense  cones  of  the  horny  layer  of  the  epidermis,  more 
or  less  concentrically  disposed,  with  sclerosis  of  the  connective  tissue 
and  a  relatively  unchanged  rete.  In  this  last  particular  the  dense 
plaque  of  ichthyosis  differs  in  texture  from  the  wart"  (Hyde). 

Sjnnptoms. — Ichthyosis  displays  wide  variation  in  its  symptoms. 
In  one  individual  it  amounts  to  slight  inconvenience,  while  in  another 
it  may  manifest  itself  in  so  pronounced  a  manner  as  to  be  the  source  of 
great  deformity  and  discomfort.     The  two  varieties  named  represent 


ICHTHYOSIS  729 

merely  accentuated  types  of  the  disorder,  rare  in  its  fullest  develop- 
ment, and,  in  the  slightest,  much  more  common  than  is  generally 
believed. 

A  simple  dryness  and  harshness  of  the  skin,  with  only  slight  furfur- 
aceous  exfoliation,  is  termed  xeroderma. 

Ichthyosis  simplex  is  the  more  common  variety,  consisting  of  a  harsh, 
dry  condition  of  the  whole  surface,  accompanied  by  the  production  of 
variously  sized  and  shaped  reticulated  scales,  either  small,  thin,  and 
furfuraceous,  like  bran,  or  large  and  thick,  resembling  fish-scales. 
Upon  the  extremities,  the  scales  usually  form  diamond-shaped  or 
polygonal  plates,  separated  from  one  another  by  furrows  or  lines 
which  extend  down  to  the  normal  skin.  In  color,  the  scales  are  either 
whitish,  grayish,  or  yellowish,  and  often  have  a  silvery  or  glistening 
appearance.  Rarely  the  color  is  olive-green  or  blackish  {ichthyosis 
nigricans).  The  amount  of  scaling  depends  upon  the  age  of  the 
patient  and  the  duration  and  severity  of  the  disease. 

Ichthyosis  Hystrix. — With  or  without  the  development  of  the  above 
variety,  in  this  the  hypertrophy  of  the  skin  may  occur  in  circum- 
scribed patches  or  large  areas,  consisting  of  irregularly  shaped  verru- 
cous, corneous,  corrugated,  wrinkled,  or  rugous  masses,  usually 
darker  in  color  than  those  of  the  simple  variety.  They  may  occur 
upon  the  arms,  as  solid,  warty  patches,  or  upon  the  back,  in  the  form 
of  elongated,  linear  patches.  They  may  constitute  roughened,  cor- 
rugated, papillary  growths,  or  uneven,  horny,  blunt,  or  pointed, 
spinous,  warty  formations.  In  the  latter  case  the  elevations  may 
reach  several  lines  or  more,  and  stand  out  from  the  skin  like  quills 
upon  the  back  of  a  porcupine — hence  the  name  hystrix.  The  amount 
and  extent  of  the  hypertrophy  varies;  the  older  the  patient,  the 
more  highly  developed  it  will  usually  be. 

Course. — Ichthyosis  simplex  may  involve  the  entire  surface  uni- 
formly or  appear  more  marked  on  the  extremities,  from  the  hips  to  the 
ankles  and  the  arms  and  forearms.  The  affection  is  always  worse 
in  winter  than  in  summer,  the  increased  activity  of  the  sweat  glands 
at  this  season  producing  the  most  beneficial  results.  The  course  of 
the  affection  is  essentially  chronic,  continuing  throughout  life,  now 
better,  now  worse.     Slight  itching  usually  occurs. 

Diagnosis. — The  characteristics  of  the  affection  are  so  peculiar 
that  an  error  in  diagnosis  is  hardly  possible.  It  is  to  be  distinguished 
from  the  inflammatory  affections  of  the  skin  which  terminate  in 
desquamation  by  the  absence  of  any  history  of  inflammation. 


730  VERRUCA 

Prognosis. — While  much  can  be  done  to  alleviate  the  affection, 
the  prognosis  is  unfavorable  as  regards  permanent  relief. 

Treatment. — Local  measures  are  alone  of  value  for  ichthyosis. 
The  maceration  of  the  accumulated  masses  of  epithelial  hyper- 
trophy is  accomplished  by  water-baths,  either  simple  or  medicated. 
The  relief  thus  afforded  the  patient,  while  temporary,  is  comforting. 
Vapor  and  alkaline  baths  are  also  serviceable.  Another  valuable 
agent  is  soft  soap  in  conjunction  with  baths,  or  alone,  as  a  discutient. 
For  severe  cases,  "sl  sufficient  quantity  is  to  be  rubbed  into  the  skin 
twice  daily  for  four  or  six  days,  during  which  period  the  patient  is 
to  refrain  from  bathing.  A  bath  is  first  taken  four  or  five  days 
after  the  last  rubbing,  when,  in  fact,  the  epidermis  has  begun  to  peel 
off;  afterward  inunction  with  a  simple  ointment  is  to  be  applied  in 
order  to  prevent  Assuring  of  the  new  skin." 

The  following  is  a  useful  formula : 

I^.     Adipis  benzoat 5  j  32  .o  gm. 

.    Glycerini lUxl  2  . 6  c.c. 

Petrolat Bss  16.0  gm. 

M.  S. — Apply  daily,  after  washing  or  bathing. 
Or— 

I^.     Potassii  iodidi gr.  xx  1.3  gm. 

Olei  bubuli f  §ss  15.0  c.c. 

Adipis 5  ss  16.0  gm. 

Glycerini f  5ij  8.0  c.c. 

M.  S. — Apply  after  bathing  (^^lilton). 

VERRUCA 

Synonjmi. — Wart . 

Definition. — A    wart    consists    of    a    circumscribed    hypertrophy 

of  the  papillary  layer,  with  more  or  less  epidermal  accumulation 
characterized  by  the  appearance  of  a  hard  or  soft,  rounded,  flat, 
or  acuminated  formation,  of  variable  size. 

Varieties. — The  following  varieties  have  chiefly  a  descriptive 
value:  verruca  vulgaris;  verruca  plana;  verruca  filiformis;  verruca 
digitata;  verruca  acuminata. 

Cause. — Obscure.  Irritation,  uncleanliness,  and  microorganisms 
are  responsible  for  some  forms. 

Pathology. — While  the  anatomy  of  warts  differs  somewhat  accord- 
ing to  their  variety,  in  all  forms  there  exists  as  a^  basis  of  their  forma- 


-  VERRUCA  731 

tion  a  connective-tissue  growth  from  which  the  papillary  hyper- 
trophy takes  place.  The  interior  of  the  growth  is  supplied  by  one 
or  more  vascular  loops,  from  which  their  vitality  is  obtained. 

S3ntnptoms. —  Verruca  vulgaris,  or  the  ordinary  wart  commonly 
seen  on  the  hands,  consists  of  a  small,  circumscribed,  elevated  growth 
having  a  broad  base  seated  securely  upon  the  skin.  Their  consist- 
ency is  either  soft  or  firm,  the  surface  smooth  or  rough,  and  the  color 
that  of  the  surrounding  skin,  or  yellowish,  brownish,  or  even  blackish. 
They  may  develop  upon  any  region  of  the  body  but  are  most  com- 
monly seen  upon  the  hands  and  fingers. 

Verruca  plana  differs  from  the  vulgaris  in  being  flat  and  broad  in 
form,  and  but  slightly  raised  above  the  level  of  the  surrounding  skin. 
Their  most  common  location  is  either  on  the  back  or  forehead. 

Verruca  filiformis  assumes  the  shape  of  a  minute,  thin,  conical, 
or  thread-like  formation,  about  ^  inch  in  length.  The  most  fre- 
quent location  is  the  face,  eyelids,  and  neck. 

Verruca  digitata  consists  of  a  slightly  elevated,  broad  formation, 
about  the  size  of  a  split  pea,  and  marked  by  a  number  of  digitations 
coming  from  its  border,  giving  an  appearance,  in  marked  cases,  re- 
sembling a  crab.     Their  most  frequent  site  is  upon  the  scalp. 

Verruca  acuminata,  known  also  as  the  pointed  wart,  the  moist 
wart,  the  pointed  condyloma,  cauliflower  excrescence,  and  venereal 
wart,  consists  of  one  or  more  groups  of  irregularly  shaped  elevations, 
often  so  closely  packed  together  as  to  form  a  more  or  less  solid  mass 
of  vegetations  {verrucce  vegetantes).  Their  color  depends  somewhat 
upon  the  degree  of  vascularity,  varying  from  a  pinkish,  bright-red 
to  a  purple  color.  They  occur,  for  the  most  part,  about  the  genitalia 
of  either  sex.  Upon  the  penis  they  usually  spring  from  the  glans  and 
the  inner  surface  of  the  prepuce.  From  the  inner  surface  of  the  labia 
and  from  the  vagina  in  the  female.  They  are  also  seen  about  the 
anus,  mouth,  axillae,  umbilicus,  and  toes.  They  may  be  either 
moist  or  dry,  according  to  their  location.  About  the  genitalia,  a 
yellowish,  puriform  secretion  usually  covers  their  surface,  due  to 
friction  and  maceration,  which,  owing  to  the  heat  of  the  parts, 
rapidly  decomposes,  producing  a  highly  offensive,  penetrating,  and 
disgusting  odor.  Their  size  varies  from  that  of  a  pea  to  that  of  an 
almond,  an  egg,  or  even  the  fist.  Their  development  is  rapid,  at- 
taining considerable  size  in  a  few  weeks. 

Prognosis. — Favorable. 

Treatment. — For  the  smaller  warts,  excision  by  means  of  the 


732  MOLLUSCUM  EPITHELIALE 

knife  or  scissors  affords  the  most  satisfactory  results.  If  the  growth 
be  large,  and  likely  to  be  attended  with  considerable  hemorrhage, 
as  in  cases  of  condyloma  about  the  genitalia,  the  galvanocaustic 
wire  or  the  Paquelin  cautery  are  to  be  preferred.  Transfixing  the 
growth  in  several  directions  with  long  needles  dipped  in  a  50  per  cent, 
solution  of  chromic  acid  has  been  recommended.  The  local  applica- 
tion of  caustics  such  as  glacial  acetic  acid,  trichloracetic  acid,  nitric 
acid,  nitrate  of  silver,  or  chromium  trioxide  is  often  satisfactory. 
Painting  of  the  growth  with  tincture  of  thuja  occidentalis  until  their 
size  is  considerably  reduced  and  then  snipping  them  off  with  scissors 
is  also  a  very  efficient  mode  of  treatment.  The  following  applications 
are  of  value : 

I^.     Acidi  salicylici 5ss  2.0  gm. 

Ext.  cannab.  indicas gr.  v  to  x      o .  3  to  o .  6  gm. 

Collodii f  §  ss  to  j      15 .  o  to  30 .  o  c.c. 

M.  S. — Apply  once  or  twice  daily. 
Or— 

I^.     Acidi  salicylici 

Acidi  borici aa  gr.  xv  aa  i .  o  gm. 

Hydrargyri  chlor.  mitis. . .  .   gr.  x  0.6  gm. 

M.  S. — Sprinkle  over  twice  daily. 
Radium  and  the  x-rays  have  effected  the  removal  of  single  warts. 

MOLLUSCUM  EPITHELIALE 

Synonyms. — MoUuscum  contagiosum;  molluscum  sebaceum. 

Description. — An  infrequent  epithelial  affection  characterized 
by  the  formation  of  discrete,  pin-head  to  pea-sized,  wax-like,  whitish 
or  pinkish  elevations,  the  summits  of  which  are  flattened  and  have  a 
central  opening  through  which  a  cheesy  fluid  may  be  squeezed. 
It  occurs  usually  in  children  and  is  slightly  contagious.  The  lesions 
occur  with  greatest  frequency  on  the  eyelids  and  cheeks  but  may 
occur  on  the  trunk.  They  grow  very  slowly  and  often  disappear 
spontaneously  by  a  process  of  sloughing  but  leaving  behind  no  scar. 
Excision  or  cauterization  may  be  performed  for  their  removal.  Oint- 
ment of  ammoniated  mercury  is  useful  in  slight  cases. 

COMEDO 

Synonj^ms. — Acne  punctata  nigra;  blackheads  or  worms. 
Definition. — A  disorder  of  the  sebaceous  glands;   characterized 


COMEDO  733 

by  the  retention  in  the  excretory  ducts  of  an  inspissated  secretion 
which  is  visible  upon  the  surface  as  yellowish  or  whitish  pin-point 
and  pin-head-sized  elevations,  containing  in  their  centers  blackish 
points. 

Causes. — The  exact  etiology  is  unknown.  Among  the  causes 
assigned  are  anemia,  menstrual  disorders,  urethral  irritations,  dys- 
pepsia, and  constipation.  Acne  vulgaris  is  often  associated  with 
this  condition. 

Pathology. — Comedo  is  an  affection  of  the  sebaceous  glands  and 
ducts,  consisting  of  an  accumulation  of  sebum  and  epithelial  cells  in  the 
glands  and  follicles,  dilating  the  ducts  to  such  an  extent  as  to  produce 
the  point  or  elevation  upon  the  surface.  The  obstructed  gland  may 
relieve  itself,  or  it  may  continue  distending  until  a  papule  is  formed. 
The  duct  sometimes  contains  small  hairs,  and  also  the  microscopic 
mite,  Demodex  folliculorum — having  a  length  of  from  H50  to  3^5 
inch,  and  breadth  of  about  >^oo  inch — which  was  at  one  time  sup- 
posed to  be  the  cause  of  the  affection. 

S3nnptoms. — The  affection  is  observed  for  the  most  part  on  the 
face,  neck,  chest,  and  back.  Each  elevation  or  blackhead  or  point  is 
designated  a  comedo;  if  a  number,  comedones. 

Each  comedo  is  small,  varying  from  a  pin-point  to  a  pin-head  in 
size,  having  a  brownish  or  blackish  appearance,  from  the  dust  or 
dirt  that  has  adhered  to  the  unctuous  surface.  If  they  form  in  great 
numbers  upon  the  face  they  are  disfiguring,  giving  the  individual 
the  appearance  of  having  had  minute  grains  of  powder  implanted  in 
the  skin.  There  are  no  evidences  of  inflammation  unless  acne  is 
associated,  but,  on  the  contrary,  the  skin  has  a  dirty,  greasy,  un- 
washed appearance. 

Diagnosis. — There  is  no  condition  resembling  comedo,  so  that 
its  recognition  is  easy,  unless  complicated  with  acne;  but  even  then 
the  inflammatory  appearance  of  acne  should  prevent  error. 

Prognosis. — Favorable,  although  often  remarkably  obstinate. 

Treatment. — Derangement  of  any  of  the  functions  of  the  body 
should  be  corrected,  and  strict  attention  be  given  to  the  rules  for 
promoting  the  general  health. 

Local  measures  are  usually  sufficient.  The  parts  should  be  thor- 
oughly softened  by  bathing  with  soap  and  warm  water,  when  the 
comedones  are  removed  by  friction  with  a  Turkish  towel,  pressure 
between  the  thumb  nails,  or  by  means  of  the  instrument  known  as  the 
"comedo-extractor,"  and  their  return  prevented  by  an  ointment 


734  "  MILIUM 

medicated  to  meet  the  indications  with  either  sulphur,  alkalies,  or 
mercury. 

Shoemaker  recommends  the  following  formula: 

I^.     Thymol gr.  x  0.65  gm. 

Acidi  borici 5ij  8.0    gm. 

Aquae  hamamel.  Virg.  dest.   f5iv  15 -O    c.c. 

Aquae  rosas f§j  30.0    c.c. 

M.  S. — Mop  well  over  surface  once  or  twice  daily. 

MILIUM 

Sjmonyms. — Grutum;  acne  punctata  albida;  strophulus  albidus. 

Definition. — An  accumulation  of  sebum  in  the  sebaceous  glands 
that  are  minus  their  excretory  ducts,  characterized  by  the  formation 
of  small,  roundish,  whitish,  sebaceous,  non-inflammatory  elevations, 
situated  immediately  beneath  the  epidermis. 

Cause. — The  origin  of  the  affection  is  not  understood. 

Pathology. — The  sebaceous  gland  is  distended  with  the  sebum, 
which  is  unable  to  escape,  owing  to  the  obliteration  of  the  duct, 
nor  can  the  contents  be  squeezed  out,  as  no  sign  of  aperture  is  to 
be  found,  the  formation  being  completely  enclosed.  Rarely  the 
retained  secretion  undergoes  a  metamorphosis  into  hard,  calcareous, 
stone-like  masses — sebaceous  concretions  or  cutaneous  calculi. 

Sjmiptoms. — Milia  may  occur  upon  any  portion  of  the  body; 
their  usual  seat,  however,  is  upon  the  face,  forehead,  and  about 
the  eyes.  They  form  gradually,  are  about  the  size  of  a  millet-seed, 
of  a  whitish,  pearl,  or  yellowish  color,  hard,  and  of  a  rOunded  shape, 
giving  the  sensation  to  the  touch  of  hard  bodies  embedded  in  the 
skin.     They  are  not  associated  with  inflammatory  symptoms. 

Diagnosis. — Milium  and  comedo  are  somewhat  similar  in  appear- 
ance; the  differences  are  that  in  milium  the  sebaceous  gland  is  dis- 
tended without  an  opening,  while  in  comedo  the  duct  of  the  gland 
is  always  patulous  upon  the  surface.  Milium  usually  exists  singly, 
the  skin  looking  normal;  while  comedo  is  more  general,  the  surface 
having  a  soiled  and  greasy  appearance. 

Prognosis. — Favorable. 

Treatment. — As  a  rule,  no  treatment  is  needed,  the  number  being 
few  and  their  presence  of  no  consequence. 

If  their  removal  be  desirable,  two  modes  suggest  themselves,  one, 
to  open  the  cyst  with  a  fine-bladed  bistoury,  turning  the  contents 


HYPERTRICHOSIS  735 

out  and  destroying  the  remaining  sac  by  the  application  of  either 
tincture  of  iodine  or  chromic  acid;  or  the  cyst  may  be  destroyed  by 
electrolysis. 

SEBACEOUS    CYST 

Synonyms. — Wen;  sebaceous  tumor;  encysted  tumor;  atheroma; 
steatoma. 

Definition.— A  distention  of  the  sebaceous  gland  and  duct,  with 
hypertrophy  of  the  walls,  forming  a  thick,  tough  sac  or  cyst,  charac- 
terized by  a  firm  or  soft,  more  or  less  rounded  tumor,  having  its  seat 
in  the  skin  or  subcutaneous  connective  tissue. 

Cause. — Unknown. 

Symptoms. — The  development  of  wens  is  slow  and  insidious. 
The  localities  where  they  are  most  Commonly  observed  are  the  scalp, 
face,  back,  and  scrotum.  The  tumors  occur  singly  or  in  numbers;  in 
size  from  a  pea  to  a  walnut,  or  larger;  in  shape  either  rounded,  flat- 
tened, or  semiglobular;  in  consistency  they  are  either  hard  or  soft 
and  doughy;  they  are  freely  movable  and  painless. 

Treatment. — Excision,  with  careful  and  thorough  dissection  of 
the  cyst  (including  the  capsule)  is  the  only  satisfactory  mode  of 
treatment. 

KERATOSIS  PILARIS 

A  cutaneous  affection  characterized  by  pin-head  sized  papules 
situated  at  the  mouths  of  the  follicles  resulting  from  epidermal  ac- 
cumulations of  hypertrophy.  The  lesions  are  grayish,  whitish,  or 
blackish  in  color  and  are  found  most  frequently  on  the  extensor  sur- 
faces of  the  extremities.  The  skin  is  dry  and  rough  but  there  is  no 
itching.  Infrequent  bathing  is  believed  to  be  the  most  common 
cause.  Bathing  with  soft  soap  and  alkaline  water,  followed  by  vigor- 
ous friction,  and  inunctions  of  petrolatum  constitute  the  treatment. 

HYPERTRICHOSIS 

Synonyms.— Hirsuties ;  hypertrophy  of  the  hair;  superfluous  hair. 

Definition. — A  local  or  general  overgrowth  of  the  hair,  either  in 
normal  or  abnormal  situations.  When  the  growth  occurs  upon  a 
mole  it  constitutes  ncsvus  pilosus.  The  cause  of  hypertrichosis  is 
unknown.     Some  cases  apparently  arise  from  local  irritation. 

Treatment. — Removal  of  the  hairs  by  means  of  electrolysis  is  the 


736  ELEPHANTIASIS 

only  satisfactory  method  of  treatment.  Shaving,  extraction,  and  the 
use  of  depilatories  are  only  of  temporary  value;  but  if  a  depilatory  is 
wanted,  the  sulphide  of  barium  depilatory,  recommended  by  Duh- 
ring  is  one  of  the  best: 

I^.     Barii  sulphid 5ij  8  gm. 

Pulv.  zinci  oxidi 

Pulv,  amyli aa    5iij  12  gm. 

ELEPHANTIASIS 

Elephantiasis  is  the  hypertrophic  condition  of  the  skin  and  under- 
lying tissue,  having  its  origin  in  lymphatic  obstruction  and  character- 
ized by  edema,  enlargement,  thickening  of  the  skin,  overgrowth  of  the 
papillae,  and  pigmentation.  The  causal  lymphatic  obstruction  may 
be  due  to  tumors,  cicatrices,  erysipelas,  and  the  filaria  sanguinis 
hominis.  It  is  most  common  in  the  tropics  and  is  most  often  observed 
in  male  adults.  The  structural  changes  incident  to  the  disease  are 
hypertrophy  of  the  entire  skin  and  subcutaneous  tissue,  edema  of 
affected  structures,  and  dilatation  of  the  blood-vessels  and  lymphatics 
with  inflammation  of  the  latter.  The  disease  usually  affects  the  leg 
and  foot  but  the  genitalia  may  be  attacked. 

The  early  stages  of  the  disease  consist  of  recurring  attacks  of  an 
erysipelatoid  inflammation.  Restoration  to  normal  is  never  com- 
plete and  with  each  succeeding  attack  the  part  becomes  larger.  In 
a  well-marked  case,  the  enlargement  is  very  great  and  the  skin  is 
thickened,  pigmented,  fissured,  and  covered  with  papillomatous  out- 
growths. The  affection  is  essentially  chronic  and  pain  is  absent 
except  in  acute  exacerbations.  The  fully  established  disease  is  incur- 
able; but  in  the  early  stages  sedative  applications,  elastic  compression, 
and  mercurial  inunctions,  together  with  nutritious  food,  tonics, 
hygiene,  etc.,  may  arrest  its  progress.  In  marked  enlargement  resort 
to  surgical  means  is  necessary. 

ONYCHAUXIS 

Hypertrophy  of  the  nails.  It  may  be  congenital  or  acquired, 
idiopathic  or  symptomatic.  Among  the  principal  diseases  to  which 
it  may  be  due  may  be  mentioned  syphilis,  psoriasis,  leprosy,  ring- 
worm, ichthyosis,  and  neuritis.  Traumatism  may  induce  it.  Treat- 
ment is  unsatisfactory  and  very  variable. 


SCLERODEEMA  737 

ATROPHIES  OF  THE  SKIN 

ALBINISM 

Albinism  consists  in  a  congenital  absence  of  pigment  in  the  hair, 
skin,  and  eyes.  The  cause  is  unknown.  It  is  believed  to  be  influ- 
enced by  heredity.  In  a  typical  case  the  skin  is  unusually  white; 
the  hair  is  fine  and  silky,  and  whitish  or  yellowish  white  in  color;  the 
pupils  appear  red;  and  the  irides  are  lighter  in  color  than  normal. 
Sensitiveness  to  light,  nictitation,  nystagmus,  high  errors  of  refraction, 
and  mental  inferiority  are  rather  common  accompaniments.  Partial 
albinism  is  common  in  negroes  and  such  individuals  are  termed 
''piebald."     Treatment  is  of  no  avail. 

VITILIGO 

Synonym. — Leukoderma. 

Description. — An  acquired  condition  characterized  by  areas  devoid 
of  pigment  surrounded  by  hyperpigmented  borders.  It  occurs  usu- 
ally in  adult  life  and  seems  to  be  dependent  upon  some  disturbance  of 
innervation.  Apart  from  this,  the  cause  is  obscure.  The  affected 
areas  are  attended  by  no  changes  other  than  loss  of  pigment  which 
may  also  be  absent  from  the  hair  in  those  regions.  Its  onset  is  slow 
and  its  course  indefinite.  It  usually  persists  during  the  life-time  of 
the  individual.  The  treatment  is  unsatisfactory.  Arsenic  inter- 
nally, and  counterirritation  to  the  patches  may  be  tried. 

SCLERODERMA 

Synonyms. — Sclerema;  hidebound  disease. 

Description. — A  rare  atrophic  cutaneous  affection,  characterized 
by  circumscribed  or  diffused  induration,  rigidity,  and  stiffening. 
It  occurs  usually  in  adult  females.  The  direct  cause  is  unknown. 
Exposure,  rheumatism,  neurotic  disturbances,  etc.,  may  influence 
its  production.  The  disease  begins  with  stiffening  and  pigmentation 
of  the  integument.  This  increases  and  is  followed  by  induration  and 
rigidity.  The  skin  meanwhile  becoming  atrophic.  The  surface  of 
the  skin  is  dry,  smooth,  and  tense.  In  a  marked  case  the  joints  also 
become  fixed.  In  the  early  stage  the  skin  is  thickened  but  late  in 
the  disease  it  becomes  thinned.  The  course  is  chronic  and  the 
prognosis  is  unfavorable.  Massage  and  inunctions  are  of  value 
in  relieving  the  tension.     Otherwise,  treatment  is  of  no  avail. 

47 


738  •  MORPHEA 

MORPHEA 

Synonyms. — Addison's  keloid;  circumscribed  scleroderma. 

Definition." — -An  atrophic  disease  of  the  skin,  characterized  by 
sharply  circumscribed,  firm,  whitish  yellow  patches,  surrounded  by 
a  violaceous  zone.  The  surface  is  smooth,  shiny,  and  resistant.  The 
lesion  is  most  common  on  the  trunk.     The  course  is  chronic. 

Treatment. — Tonics  should  be  administered  internally,  and 
massage,  electricity,  and  the  x-tslj  should  be  tried  locally.  The 
results  of  treatment,  however,  are  not  very  encouraging. 

CANITIES 

Absence  of  pigment  in  the  hair.  It  may  be  local  or  general, 
senile  or  premature.  Premature  whitening  of  the  hair  may  be  due 
to  profound  emotional  disturbances,  fright,  shock,  fear,  worry,  neural- 
gia, vitiligo,  heredity,  etc.  It  usually  takes  place  slowly  but  may 
occur  very  suddenly.  The  treatment  consists  in  the  application  of 
hair  dyes.  Internal  medication  is  useless.  The  two  following 
dyes  are  given  by  Kaposi : 

I^.     Argent,  nitrat gr.  xv  i  .0  gm. 

Ammon.  carb gr.  xxij  i .  4  gm. 

Ung.  adipis §j  30.0  gm. 

For  black  shade. 

I^.     Acidi  pyrogall gr.  xv  i  gm. 

Aq.  cologn f  Bss  15  c.c. 

Aq.  rosae f  5  jss  45  c.c. 

For  brown  shade. 

ATROPHY  OF  THE  NAILS 

This  may  result  from  injury,  disease  of  the  nerves,  syphilis,  psoriasis, 
ringworm,  etc.,  or  it  may  be  congenital.  The  nails  become  lusterless, 
brittle,  and  dwarfed.  Treatment  depends  upon  the  cause  but  even 
in  the  most  favorable  cases  some  deformity  remains. 

ALOPECIA 

Synonyms. — Baldness;  calvities. 

Description. — Partial  or  complete  loss  of  hair.  It  may  be  con- 
genital or  acquired.     The  acquired  form  may  be  senile  or  premature, 


ALOPECIA   AREATA  739 

idiopathic  or  symptomatic.  The  idiopathic  variety  occurs  without 
obvious  internal  or  external  causes  and  is  seldom  amenable  to  any 
form  of  treatment.  Symptomatic  alopecia  is  that  form  of  the  af- 
fection which  results  from  syphilis,  infectious  fevers,  seborrhea,  lupus 
erythematosus,  parasitic  diseases  of  the  skin,  psoriasis,  eczema,  and 
similar  conditions. 

The  prognosis  depends  on  the  cause.  In  congenital,  senile,  and 
idiopathic  alopecia  the  hair  seldom  regenerates.  In  symptomatic 
alopecia,  the  possibility  of  return  of  the  hair  is  directly  proportionate 
to  the  removability  of  the  cause. 

Treatment. — This  varies  with  the  underlying  cause.  Internally, 
tonics,  especially  strychnine,  iron,  and  arsenic,  together  with  fluid- 
extract  of  jaborandi,  T([x  (0.65  c.c),  three  times  daily  should  be 
administered.  Locally,  stimulating  applications  should  be  made 
varying  with  the  character  of  the  local  cause.  Seborrhea  being  a 
very  frequent  cause,  its  treatment  is  applicable  to  most  cases. 

ALOPECIA  AREATA 

Description. — Baldness  in  circumscribed  areas.  These  areas 
occasionally  coalesce,  producing  alopecia  universalis.  Most  cases 
are  due  to  some  disturbance  of  the  nervous  system  while  others  seem 
to  owe  their  origin  to  a  parasite.  The  condition  is  one  of  atrophy 
and  effects  the  entire  hair  and  the  adjacent  skin.  The  most  common 
situations  for  the  disease  are  the  scalp,  beard,  eyebrows,  and  eyelashes, 
but  in  very  rare  instances  the  pubic  and  axillary  hair  may  also  be 
lost.  As  ordinarily  observed,  the  disease  presents  one  or  more 
rounded,  circumscribed,  smooth,  white  patches  of  baldness.  There 
are  no  prominent  follicles  or  broke n-off  hairs  a*s  in  ringworm.  The 
skin  may  at  first  be  somewhat  inflammatory  but  soon  becomes  pale 
and  atrophic.  The  onset  may  be  sudden  or  gradual  and  the  duration 
is  indefinite. 

Prognosis. — The  course  is  rather  chronic.  Recovery  is  the  rule 
in  children  but  usually  requires  a  period  of  several  months.  In 
older  persons  the  prognosis  should  be  guarded,  the  hair  returns  but 
requires  a  much  longer  period.  In  middle-aged  or  older  adults,  the 
outlook  for  the  return  of  the  hair  is  unfavorable.  Relapses  are  com- 
mon. The  return  of  the  hair  is  evidenced  first  by  the  appearance  of 
fine,  white,  downy  hairs  over  the  affected  areas;  these  later  become 
converted  into,  or  are  replaced  by,  the  natural  hair. 


740  KELOID 

Treatment. — Tonics    should    be    administered    internally.     Aif 
senical  preparations  are  especially  valuable.     Fluidextract  of  jaboi 
andijTtlx  (0.65  c.c),  is  very  beneficial  in  some  cases.     Locally,  stimt 
lating  applications  should  be  employed.     The  following  is  an  example 

I^.     Betanaphthol 5j  4  gm. 

Petrolat 5j  32  gm. 

M.  S. — Apply  locally  twice  daily. 

NEW  GROWTHS  OF  THE  SKIN 

KELOID 

Synonyms. — Cheloid;  keloid  of  Alibert. 

Description. — An  abnormal  growth  of  connective  tissue  develof 
at  the  site  of  an  injury.  It  is  observed  most  frequently  in  negroe 
and  usually  follows  lacerations,  burns,  bites,  and  destructive  lesioni 
Occasionally  it  arises  spontaneously.  In  the  early  stages,  the  growt 
appears  as  a  small,  pale-red  nodule  but  as  it  progresses  it  increases  i 
size,  sending  out  claw-like  processes.  It  is  smooth,  dense,  and  of 
pinkish  color  but  may  be  darkly  pigmented.  Subjective  sympton 
are  absent.     The  affection  usually  occurs  over  the  sternum. 

Treatment. — Excision  should  never  be  performed  as  the  resultini 
scar  will  give  rise  to  greater  deformity  than  the  keloid.  Multip- 
scarification,  electrolysis,  mercurial  plaster,  and  the  a:-ray  may  t 
employed.     In  most  cases  the  growth  is  permanent. 

XANTHOMA 

Synonyms. — Xanthelasma ;  vitiligoidea. 

Definition. — An  abnormal  cutaneous  condition  characterized  b' 
the  formation  of  circumscribed  fiat  or  tubercular  yellowish  patche 
The  fiat  variety,  xanthoma  planum,  is  most  often  observed  on  tl 
eyelids  and  consists  of  smooth,  soft,  sharply  circumscribed,  but 
colored,  slightly  elevated  patches.  The  tubercular  form,  xanthon, 
tuberosum,  occurs  elsewhere  on  the  body  as  variously  sized,  smootl 
elastic,  yellow  nodules. 

Causes. — Frequently  no  cause  can  be  detected.  Female  se] 
middle  life,  jaundice,  and  diabetes  are  factors  in  some  cases. 

Treatment. — Usually  no  treatment  is  necessary,  as  the  growtl 
usually  remain  stationary.     Removal  may  be  accomplished  by  ele 


LUPUS   ERYTHEMATOSUS  74 1 

•olysis  if   necessary.     Excision   or   the  galvanocautery  is    seldom 
ecessary. 

LUPUS  ERYTHEMATOSUS 

Synonyms. — Seborrhea  congestiva;  lupus  non-ex  edens;  lupus 
rythematodes ;  lupus  sebaceus. 

Definition. — A  chronic,  superficial,  new-growth  formation  of  the 
kin  characterized  by  sharply  circumscribed  reddish  patches  covered 
nth  adherent  grayish  or  yellowish  scales. 

Causes. — The  etiology  is  obscure.  The  disease  is  observed  with 
reatest  frequency  in  the  female  sex  during  early  and  middle  adult 
fe.  Many  cases  are  preceded  by  local  congestive  disorders  such  as 
cne  rosacea,  seborrhea,  eczema  seborrhoicum,  sunburn,  chilblains, 
tc.  General  ill  health  is  also  an  etiological  factor.  By  many  ob- 
ervers,  the  affection  is  believed  to  be  an  expression  of  tuberculosis. 

Pathology. — The  true  nature  of  the  affection  has  not  been  as  yet 
lefinitely  determined.  Many  observers  believe  it  to  be  a  new  growth 
/hile  others  view  it  as  a  chronic  inflammation.  The  earliest  change 
3  believed  to  be  capillary  obstruction.  The  principal  structural 
Iterations  of  the  disease  are  to  be  found  in  the  corium,  consisting 
argely  of  a  growth  of  reticulated  adenoid  tissue,  associated  with 
j)eri vascular  infiltration.  The  excretory  parts  of  the  glandular 
tructures  are  to  some  extent  infiltrated.  Edema  of  the  prickle 
:ells  and  cutis  is  also  present.  The  scarring  may  result  from  degenera- 
ion  of  the  sebaceous  glands  or  the  elastic  fibers.  The  epidermis 
sventually  becomes  atrophic.  The  affection  is  believed  to  result 
rom  the  toxin  of  tuberculosis,  but  the  lesion  possesses  none  of  the 
:haracteristics  of  tuberculous  growths. 

Symptoms. — The  disease  presents  itself  in  four  clinical  varieties: 
circumscribed,  diffuse,  telangiectatic,  and  nodular.  The  circum- 
;cribed  form  is  perhaps  the  more  common  and  is  the  variety  usually 
)bserved  on  the  nose,  cheeks,  ears,  and  scalp.  Attention  is  first  called 
;o  the  condition  by  the  presence  of  one  or  more  pin-head  to  pea-sized, 
;caly,  reddish  spots,  the  borders  of  which  may  be  elevated.  They 
^row  slowly,  as  a  rule,  and  after  a  certain  size  is  attained  they  may 
"emain  stationary  or  coalesce  forming  large  patches.  These  patches 
ire  well  defined  and  sharply  marginated,  being  separated  from  the 
lealthy  integument  by  an  elevated  border.  The  surface  of  the  lesion 
s  covered  with  scanty  grayish  scales  which  are  firmly  adherent  and 


i 


742  •  LUPUS    ERYTHEMATOSUS 

project  into  the  follicular  openings.  The  central  portion  of  the  dis- 
ease is  slightly  depressed  and  atrophic  and  the  ducts  of  the  sebaceous 
glands  are  distended  and  patulous.  The  color  of  the  patch  is  pinkish 
or  reddish  with  a  violaceous  tinge,  most  marked  at  the  border.  On 
taking  the  affected  skin  between  the  fingers  it  is  found  to  be  infiltrated 
and  thickened.  Mild  itching  and  burning  are  present.  A  common 
situation  for  the  disease  is  the  face,  involving  both  cheeks  and  the 
nose  at  the  same  time  and  presenting  the  appearance  of  a  butterfly 
with  outstretched  wings.  Less  frequently  the  ears,  scalp,  hands,  and 
mucous  membranes  may  be  attacked.  The  lesions  are  usually  sym- 
metrically distributed.  The  course  of  the  disease  is  essentially 
chronic.  Involution  occasionally  occurs  spontaneously  but  malig- 
nant changes  are  very  rare. 

Diagnosis. — Lupus  erythematosus  may  be  distinguished  from  other 
affections,  especially  lupus  vulgaris,  by  its  occurrence  in  adult  life, 
its  slow  course,  its  symmetrical  distribution,  the  superficial  character 
of  the  sharply  defined  scaly  patches  with  distended  glandular  open- 
ings, the  atrophic  scarring,  and  the  absence  of  ulceration  or  nodules. 

Prognosis. — The  course  of  the  disease  is  very  chronic  and  extends 
over  several  years.  Many  cases  never  show  any  improvement.  A 
few  undergo  spontaneous  involution;  and  a  limited  number  respond 
to  treatment.     The  prognosis  should  always  be  guarded. 

Treatment. — Internal  treatment  has  little  or  no  effect  on  the 
disease  except  in  those  instances  in  which  definite  internal  affections 
exist,  under  which  circumstances  internal  medication  is  indirectly  of 
value.     Quinine  is  sometimes  beneficial. 

Locally,  moderately  stimulating  applications  are  of  most  benefit. 
A  common  practice  is  to  wash  the  face  nightly  with  soap  (green  soap 
if  the  patch  appears  sluggish)  and  apply  some  preparation  of  sulphur 
such  as: 

I^.     Sulph.  praecip 5j  4  gm- 

Petrolat §j  32  gm. 

M.  S. — Apply  locally. 


Or- 


I^.     Zinc  sulphat 

Potass,  sulphid aa    5  J  4  gn^* 

Aquas f  Siv  120  c.c. 

(Dissolve  separately  and  then  mix.) 
S. — "Lotio  Alba" — apply  locally. 


LUPUS  VULGARIS  743 

If  much  roughness  or  irritability  results: 

I^.     Sulph.  praecip 

Acid,  salicyl aa  gr.  x  0.6  gm. 

Ung.  aquae  rosae 5j  32.0  gm. 

M.  S. — Apply  locally  (Stel wagon). 
Unna  applies  a  paint  consisting  of  10  parts  of  collodion  and  1 
to  2  parts  of  green  soap  to  which  3  to  5  per  cent,  of  salicylic  acid 
may  be  added  to  increase  its  activity.  The  application  of  mercurial 
plaster  and  the  painting  of  the  lesion  with  liquor  potassae,  carbolic 
acid,  salicylic  acid,  or  resorcin  in  collodion,  iodine,  and  silver  nitrate 
deserve  passing  mention.  Strong  caustics  are  occasionally  employed 
but  the  scarring  they  induce  is  a  disadvantage.  Among  other 
/» measures  useful  at  times  may  be  mentioned  freezing  with  carbon 
dioxide  snow  or  ethyl  chloride,  scarification,  curetting,  electrolysis, 
galvanocauterization,  phototherapy,  and  radiotherapy. 

LUPUS  VULGARIS 

S5mon3rms. — Lupus  exulcerans;  lupus  exedens;  lupus  vorax. 

Definition. — A  neoplastic  cellular  infiltration  caused  by  the 
tubercle  bacillus,  producing  papules,  nodules,  and  patches  which 
either  ulcerate  or  atrophy,  leaving  scars  (Crocker). 

Cause. — The  direct  cause  is  the  tubercle  bacillus.  The  disease 
usually  begins  in  the  first  or  second  decade  of  life  and  is  never  con- 
genital. In  many  cases  there  is  an  hereditary  predisposition.  Some 
cases  result  from  local  inoculation.  Evidences  of  tuberculosis  else- 
where are  often  present. 

Pathology. — The  process  consists  essentially  of  a  small  round- 
cell  infiltration  beginning  in  the  corium  and  gradually  invading  the 
other  layers.  Circumscribed  areas  are  encountered  which  possess 
all  the  structural  characteristics  of  miliary  tubercles  (epithelioid 
cells,  giant  cells,  etc.).  Tubercle  bacilli  may  be  demonstrated  but 
are  very  scant.  Necrotic  degeneration  takes  place  in  these  areas 
followed  by  proliferation  of  the  connective-tissue  cells  and  the 
production  of  scar  tissue. 

Sjnnptoms. — The  disease  usually  begins  on  the  face  as  one  or  more 
deep-seated,  pin-point  to  pin-head  dull  red  spots.  These  gradually 
develop  into  small,  semi  translucent,  brown  'nodules  (''apple-jelly 
nodules  of  Jonathan  Hutchinson").  As  the  disease  progresses, 
these  nodules  extend  and  eventually  coalesce  forming  dull  red,  soft, 
elevated  patches  with  firm,  more  or  less  nodular  borders.  More  or 
less  scaliness  may  be  present.     The  nodules  may  remain  stationary 


744  *    LUPUS  VULGARIS 

for  a  variable  period  but  always  terminate  either  with  ulceration 
with  scar  formation  or  in  absorption.  A  fully  developed  patch  of 
lupus  tissue  shows  the  presence  of  papules,  nodules,  fiat  infiltrations, 
ulceration,  scar  formation,  and  atrophic  areas  in  varying  degrees. 
At  times  papillomatous  outgrowths  may  be  found  on  the  border. 
Frequently  the  lesion  shows  retrograde  changes  at  one  side  and  on 
the  other  evidences  of  advancement.  Slight  pain  may  be  present. 
The  course  is  very  chronic. 

Diagnosis. — The  characteristic  features  of  this  disease  that  serve 
to  distinguish  it  from  syphilis,  epithelioma,  and  other  ulcerative 
affections  are:  the  beginning  early  in  life,  the  slow  course,  and  the 
superficial  ulcerations,  together  with  papules,  semitranslucent  nod- 
ules, flat  infiltrations,  and  scarring.  The  ulcers  are  multiple,  have 
soft  undermined  edges,  and  give  rise  to  little  or  no  pain. 

Prognosis. — In  cases  in  which  the  lesions  are  small  and  the  patient 
is  young,  cure  may  be  effected  by  appropriate  treatment.  Usually 
the  disease  is  refractory  to  treatment,  and  when  one  patch  is  de- 
stroyed another  makes  its  appearance.  The  course  is  essentially 
chronic  and  the  duration  indefinite.  The  possibility  of  systemic 
infection  should  be  borne  in  mind. 

Treatment. — In  all  cases,  the  patient  should  receive  the  treatment 
recommended  for  tuberculosis  in  general,  in  addition  to  the  various 
local  measures  for  the  diseased  integument. 

Locally,  perhaps  the  most  beneficial  with  the  least  deleterious 
results  is  the  x-rsij  treatment.  Phototherapy,  after  the  method 
of  Finsen  is  of  value  but  requires  a  long  period  of  treatment  to  be  of 
value.  Radium  has  also  been  reputed  to  be  of  benefit  but  observa- 
tions have  been  few  in  this  direction.  Extirpation  of  the  diseased 
structure  has  been  practised  extensively.  This  may  be  accomplished 
by  curetting,  cauterization,  electrolysis,  or  excision.  The  caustics 
most  commonly  employed  for  this  purpose  are  pyrogallic  acid 
(20  per  cent,  plaster),  arsenous  acid  (30  per  cent,  paste),  and  chloride 
of  zinc.  The  galvanocautery  and  Paquelin  cautery  are  also  used. 
Scarification  is  also  a  useful  method  of  treatment  in  some  cases. 

Frequently  when  first  encountered,  the  lesion  is  in  an  irritable 
state  either  as  the  result  of  previous  treatment  or  of  unknown  causes. 
In  such  cases,  soothing  applications  are  of  benefit.  Calamine  lotion, 
diachylon  ointment,  and  the  ointment  of  the  oleate  of  mercury 
(10  per  cent.),  i  dram  to  the  ounce  of  ointment  base.  Brocq  ad- 
vises the  following: 


HYPERIDROSIS  745 

I^.     Hydrarg.  oleat  (5  per  cent.)    5j  32.0  gm. 

Pulv.  zinci  oxidi 

Pulv.  amyli aa   3ij  *      8.0  gm. 

Vaselin 5iv  16.0  gm. 

Acid,  salicyl gr.  xx  1.3  gm. 

Ichthyol Tllxx  i .  3  gm. 

M.  S. — Apply  locally  twice  daily. 

Plasters  are  often  of  value,  particularly  mercurial  plaster,  sali- 
cylic acid  plaster  (20  per  cent.),  and  resorcin  plaster.  Various  other 
modes  of  treatment  may  be  employed  according  to  the  indications. 

SCROFULODERMA 

Description. — A  tuberculous  condition  of  the  skin  occurring  in 
strumous  individuals  characterized  by  ulceration  and  associated 
usually  with  suppurating  lymphatic  glands.  The  disease  begins  in 
the  lymphatic  glands  which  undergo  necrosis  discharging  through  the 
overlying  skin.  The  ulceration  in  the  skin  is  violaceous  in  color  and 
has  thin  undermined  edges,  its  base  being  made  up  of  pale  granula- 
tions. These  ulcers  may  occur  anywhere  on  the  body  but  are  most 
common  on  the  neck.  They  spread  slowly  and  sometimes  show  a 
tendency  to  heal  and.  form  connective  tissue.  Other  manifestations 
of  the  strumous  diathesis  such  as  otorrhea,  ocular  inflammations, 
lymphatic  enlargements,  etc.,  are  often  present. 

Treatment. — The  general  health  should  receive  careful  attention. 
Cod-liver  oil,  syrup  of  the  iodide  of  iron,  hydriodic  acid,  quinine,  and 
similar  drugs  should  be  administered.  Fresh  air,  sunlight,  exercise, 
bathing,  nutritious  food,  and  other  similar  measures  should  be 
prescribed. 

Locally,  salicylic  acid  (gr.  x)  in  lead  plaster  (50  per  cent.)  is  a  very 
efficient  application.  The  oleate  of  mercury,  and  boric  acid  may  also 
be  used.  The  most  efficient  method  of  treatment  is  extirpation  and 
this  may  be  accomplished  by  curetting,  excision,  or  the  use  of  caus- 
tics such  as  pyrogallol. 

DISORDERS  OF  SECRETION 

HYPERIDROSIS 

Synonyms. — Hydrosis;  ephidrosis;  idrosis. 

Definition. — -A  disorder  of  the  sweat  glands,  characterized  by  an 


746  HYPERIDROSIS 

increased  secretion  of  sweat.  The  sweating  may  be  either  general  or 
local. 

Causes. — Unknow'n.  It  may  be  inherited.  Disorders  of  the 
sympathetic  nervous  system  give  rise  to  it  in  many  instances.  The 
condition  is  purely  functional  in  character. 

Sjmiptoms. — The  affection  may  be  unilateral  or  bilateral,  local  or 
general,  acute  or  chronic,  and  constant  or  paroxysmal.  The  quan- 
tity of  secretion  may  be  comparatively  small  or  very  large. 

Local  hyperidrosis  occurs  most  commonly  upon  the  palms,  soles, 
axillae,  and  genitalia. 

Hyperidrosis  of  the  palms  may  be  so  profuse  that  the  fluid  accumu- 
lates and  keeps  the  parts  constantly  macerated,  the  wearing  of 
gloves  being  impossible,  for  as  soon  as  the  parts  are  wiped  dry  they 
are  again  bathed  in  the  secretion.  Jamieson  states  that  hyperidrosis 
of  the  hands  is  very  common  in  those  who  are  daily  excessive  spirit 
drinkers. 

Hyperidrosis  of  the  soles  is  a  disagreeable  and  often  distressing 
condition,  as  the  socks  and  shoes  become  saturated,  and  thus  keep 
the  soles  constantly  bathed,  allowing  the  macerated  epidermis  to  peel 
off,  leaving  a  more  tender  skin  exposed,  causing  pain  and  distress 
when  walking.  The  maceration  of  the  epidermis,  and  the  secretion 
about  the  toes,  together  with  the  moisture  of  the  socks  and  the  soles 
of  the  shoes,  produce  a  most  disagreeable,  disgusting,  and  persistent 
odor,  which  is  termed  hromidrosis  pedum. 

Hyperidrosis  of  the  genitalia  attacks  males  more  particularly, 
giving  rise  to  a  disagreeable,  penetrating  odor. 

Bromidrosis  is  the  designation  when  the  secretion  has  an  offensive 
odor. 

Chromidrosis  is  the  designation  when  the  fluid  poured  forth  is  vari- 
ously colored. 

Uridrosis  is  the  designation  when  the  excretion  from  the  sweat 
glands  contains  the  elements  of  the  urine,  and  particularly  urea. 

Phosphoridrosis  is  the  designation  when  the  perspiration  appears 
luminous  in  the  dark. 

Hematidrosis  is  the  designation  when  the  sweat  contains  blood. 

Prognosis. — The  majority  of  cases  are  extremely  intractable,  but 
in  local  hyperidrosis,  particularly  of  the  feet,  the  prognosis  is  favor- 
able.    Relapses  may  occur. 

Treatment. — If  the  sweating  is  generalized,  a  careful  search  should 
be  made  to  determine  the  underlying  systemic  cause  and  the  internal 


HYPERIDROSIS  747 

treatment  should  be  governed  accordingly.  Atropine  sulphate,  gr. 
H20  to  }'Qo  (0.00034  to  o.ooi  gm.),  twice  daily,  ergot  in  pill  or  solu- 
tion, agaracin,  gr.  }^  (o.oii  gm.),  gallic  acid,  quinine,  mineral  tonics, 
and  sulphur,  5  J  (4  g"i-).  twice  daily,  have  been  highly  recommended 
for  this  condition. 

Local  treatment,  however,  is  more  efficacious.  The  parts  should  be 
cleansed  and  immediately  dried,  and  then  dusted  with  some  one  of 
the  numerous  dusting  powders.     The  following  is  a  valuable  powder: 

I^.     Acidi  salicylici gr.  xx  1.3  gm. 

Zinci  cleat §  j  32 ,0  gm. 

M.  S.— Use  locally. 

Perhaps  the  very  best  local  application  is  tincture  of  belladonna 
either  diluted  or  full  strength.  Aristol  as  a  dusting  powder  is  very 
satisfactory. 

For  profuse  sweating  of  the  axillae,  the  application  of  a  sponge 
soaked  in  very  hot  water  has  been  recommended. 

In  hyperidrosis  of  the  palms  and  soles,  the  following  are  valuable, 
first  washing  the  parts  with  a  weak  solution  of  carbolic  acid: 

I^.     Acidi  salicylici 5ss  2  gm. 

Gretas  praep 5  j  32  gm. 

Aluminis  exsic Bj  32  gm. 

M.  and  powder  finely. 

S. — Apply  to  parts  with  puff-ball. 
Or— 

1$.     Acid,  salicylici 3  parts. 

Pulv.  amyli 10  parts. 

Pulv.  soapstone 87  parts. 

M.  S. — Sift  into  shoes  and  stockings. 
Or— 

I^.     Sulphur,  loti gr.  xxx  2.0    gm. 

Pulv.  arrowroot 5iv  16.0    gm. 

Acid,  salicylici gr.  vij  0-45  gin- 

M.  S. — Dust  over  feet  and  between  toes. 
Or— 

I^.     Potassii  permanganat gr.  ij  o.  13  gm. 

Aquae  destil f §j  30.0    c.c. 

M.  S. — Apply  locally. 
A  saturated  solution  of  boric  acid,  alone  or  in  powder,  with  equal 


748  AisriDROsis 

parts  of  acetanilide,  applied  frequently  to  the  hands  and  feet,  often 
proves  curative. 

For  obstinate  cases,  involving  the  palms  or  soles,  the  following 
plan  of  treatment,  as  suggested  by  Hebra,  will  be  found  of  the  greatest 
service.     It  is  imperative  that  the  various  steps  be  closely  followed: 

"The  parts  are  to  be  cleansed  with  water  and  soap,  and  the  following 
ointment  applied  on  pieces  of  cloth  cut  to  the  size  of  the  region.  Lint 
smeared  with  the  ointment  is  also  to  be  placed  between  the  toes  or 
fingers,  so  that  every  portion  of  the  skin  may  be  covered  with  a  layer 
of  the  ointment. 

I^.     Emplast.  diachyli §iv  120  gm. 

Olei  olivas. f  5iv  120  c.c. 

The  plaster  to  be  melted  and  the  oil  added  and  stirred  until 
a  homogeneous  mass  results. 

S. — To  be  used  on  cloths. 

"  The  clothes  are  to  be  changed  every  twelve  hours,  when  the  parts 
are  not  to  be  washed,  but  rubbed  with  dry  lint  and  starch  dusting 
powder,  after  which  new  dressings  are  again  to  be  applied  in  the  same 
manner.  This  proceeding  is  to  be  continued  from  one  to  two  weeks. 
When  the  disease  is  upon  the  soles,  the  patient  may  walk  about  in 
loose  shoes."  After  a  week  or  ten  days  the  ointment  may  be  discon- 
tinued, but  the  dusting  powder  is  to  be  used  for  a  considerable  period. 
If  relapses  occur,  the  original  treatment  should  again  be  instituted. 

Painting  the  soles  and  under  and  between  the  toes  with  a  i  per  cent, 
solution  of  formalin  morning,  noon,  and  night,  has  given  good  results 
in  a  number  of  instances.  A  few  drops  of  the  solution  may  be  put  in 
the  boot  or  shoe. 

Among  other  methods  of  treatment  may  be  mentioned  the  applica- 
tion of  a  I  per  cent,  alcoholic  solution  of  quinine,  the  use  of  astringent 
lotions  containing  alum,  tannic  acid,  and  similar  substances  (5j  to 
viij  to  the  pint  of  water),  the  dusting  of  tartaric  acid  on  the  parts 
when  there  are  no  abrasions,  and  the  employment  of  electricity. 

ANIDROSIS 

Definition. — A  functional  disorder  of  the  sweat  glands,  character- 
ized by  a  diminished  or  insufficient  secretion  of  sweat. 

Causes. — Anidrosis  may  be  due  to  a  congenital  deficiency  of  the 
sweat  glands  or  it  may  result  from  injury  to  a  nerve,  during  the  course 


MILIARIA  749 

of  chronic  diseases  of  the  skin,  as  ichthyosis,  eczema,  psoriasis,  lepra, 
and  elephantiasis  arabum.  In  rare  cases  an  individual  ceases  to 
sweat  entirely  at  times;  in  such  cases  the  general  health  is  impaired, 
and  during  the  hot  season  much  suffering  may  result. 

Treatment. — The  activity  of  the  skin  and  sweat  glands  should  be 
promoted  by  the  ingestion  of  large  quantities  of  water,  hot  baths, 
steam  baths,  friction,  electricity,  and  the  use  of  sudorifics,  especially 
pilocarpine.  In  congenital  cases,  the  treatment  is  of  no  benefit. 
The  harshness  and  dryness  of  the  skin  in  such  cases  may  be  relieved 
to  some  extent  by  oily  applications. 

SUDAMINA 

Synonyms. — Sudamen ;  miliaria  crystallina  (Hebra) . 

Definition. — A  non-inflammatory  affection  of  the  sweat  glands; 
characterized  by  the  rapid  development  of  millet-seed-sized,  translu- 
cent, whitish  vesicles  in  great  numbers  upon  any  portion  of  the  body. 

Cause. — A  high  bodily  temperature,  causing  unusual  activity  of  the 
sudoriparous  glands.     The  affection  is  common  in  febrile  diseases. 

Pathology. — The  glands  being  excited  beyond  their  capacity  for 
normal  excretion,  the  excessive  fluid,  instead  of  escaping  upon  the 
surface,  collects  between  the  layers  of  the  epidermis,  in  the  form  of 
minute,  translucent  pin-point-sized  vesicles. 

Symptoms. — An  ephemeral  rash.  Each  minute  vesicle  is  distinct, 
but  they  exist  in  great  numbers,  very  closely  resembling  drops  of  free 
sweat.  They  develop  rapidly,  never  coalesce,  become  puriform,  or 
rupture.  Fresh  crops  form  from  time  to  time.  Their  duration  is 
transitory;  the  fluid  is  absorbed,  the  covering  of  each  dries,  forming  a 
thin,  delicate  membrane,  which  disappears  as  a  slight  desquamation. 

Treatment. — The  treatment  is  that  of  the  disease  with  which  they 
occur. 

MILIARIA 

Synonyms. — ^Lichen  tropicus;  miliaria  rubra;  miliaria  alba;  prickly 

heat. 

Definition. — An  acute  inflammation  of  the  sweat  glands,  character- 
ized by  the  development  of  discrete,  whitish  or  reddish,  pin-point  and 
millet-seed-sized  papules,  vesicles,  or  vesiculopapules,  production  of 
prickling,  tingling,  and  burning  sensations  of  a  most  aggravated 
character,  associated  with  more  or  less  malaise. 


750  MILIARIA 

Causes. — Excessive  heat,  the  result  of  excessive  or  tightly  fitting 
clothing,  or  a  high  external  temperature  is  the  exciting  cause.  The 
affection  is  most  frequent  in  fleshy  adults  who  perspire  freely,  and  in 
children.  Nervous  prostration,  severe  dyspepsia  and  general  debility 
seem  to  predispose  to  "prickly  heat. " 

Varieties. — Miliaria  papulosa;  miliaria  vesiculosa. 

Pathology. — The  pathology  of  the  two  varieties  is  the  same — both 
inflammatory  affections  of  the  sweat  glands;  in  the  one  papules,  in 
the  other  vesicles,  develop  about  the  orifices  of  the  excretory  ducts. 

In  either  variety  occurs  hyperemia  of  the  vascular  plexus  of  the 
sweat  glands,  followed  by  slight  exudations  about  the  ducts,  giving 
rise  to  the  minute  papules  or  vehicles,  which  remain  until  the  cause 
has  been  modified  or  removed,  when  they  are  rapidly  absorbed. 

Symptoms. — Miliaria  papulosa,  known  as  lichen  tropicus  and 
''prickly  heat,"  is  of  sudden  onset,  with  the  occurrence  of  numerous 
minute,  acuminated  bright-red  papules,  about  the  size  of  a  pin-head 
or  millet-seed,  and  but  slightly  raised  above  the  level  of  the  skin. 
The  papules  are  preceded  by  and  accompanied  with  sweating  (hyper- 
idrosis)  and  distressing,  tingling,  pricking,  and  burning  sensations. 
If  the  attack  be  severe,  vesicopapules  and  vesicles  are  freely  inter- 
spersed among  the  numerous  papules.  Rarely  the  secretion  of  sweat 
is  notably  diminished. 

Miliaria  vesiculosa;  in  this  variety,  instead  of  papules,  immense 
numbers  of  vesicles  develop,  of  the  size  of  pin-points  and  pin -heads, 
of  a  whitish  {miliaria  alba)  or  yellowish-white  color.  The  surface 
from  which  they  arise  is  of  a  bright -red  color,  owing  to  each  vesicle 
being  surrounded  by  an  areola  {miliaria  rubra).  The  vesicles  are 
preceded  and  accompanied  by  sweating  (hyperidrosis)  and  most 
distressing  tingling,  pricking,  and  burning  sensations. 

Either  variety  may  attack  all  parts  of  the  body,  but  the  abdomen, 
chest,  back,  neck,  and  arms  are  regions  usually  invaded. 

Duration. — This  varies  with  the  cause.  It  may  appear,  fully  de- 
velop, and  disappear  in  a  few  hours.  In  those  predisposed  it  may 
continue  more  or  less  marked  throughout  the  entire  summer. 

Diagnosis. — If  the  cause,  nature,  and  seat  of  the  affection  are  taken 
into  consideration,  no  error  should  occur. 

Eczema  papulosum  has  a  resemblance  to  "prickly  heat,"  but 
the  course  of  eczema  is  slow,  and  the  papules  are  larger,  more  elevated, 
and  firmer  than  those  of  miliaria  papulosa. 

Eczema  vesiculosum  and  miliaria  vesiculosa  are  to  be  differentiated 


SEBORRHEA  75 1 

by  the  marked  differences  in  the  progress  of  each — the  former  slow, 
the  latter  rapid;  the  vesicles  of  the  former  rupturing  spontaneously, 
those  of  the  latter  only  when  severely  irritated. 

Sudamcn  is  not  an  inflammatory  affection  while  miliaria  is. 

Prognosis. — The  affection  is  often  most  rebellious  in  fleshy  per- 
sons and  children,  and  if  neglected  it  passes  into  eczema  or  an  erythe- 
matous intertrigo. 

Treatment. — The  patient  should  be  kept  as  cool  as  possible, 
and  avoid  undue  perspiration.  The  food  should  be  light  and  unstimu- 
lating,  dispensing  with  meats  and  condiments  for  a  few  days;  wine, 
spirits,  and  beer  are  to  be  avoided. 

The  ingestion  of  water,  lemonade,  ApoUinaris  water,  Vichy 
water,  together  with  refrigerant  diuretics,  as  potassium  citrate  or 
acetate,  a  cool  apartment,  and  absolute  rest  will  ordinarily  insure 
speedy  relief.     Saline  cathartics  are  invaluable. 

Locally,  sponging  with  alkaline  solutions,  dilute  subacetate  of 
lead  solution,  fluidextract  of  grindelia  (well  diluted),  or  a  solution  of 
witch  hazel  is  beneficial.  Cupric  sulphate  solution  (gr.  x  to  the 
ounce),  carbolic  acid  (gr.  xx),  and  glycerite  of  starch  (Biij),  and  a 
dusting  powder  composed  of  lycopodium,  starch,  and  zinc  oxide  may 
also  be  employed.  The  application  of  boric-acid  solution  followed 
by  boric-acid  powder  is  a  valuable  method  of  treatment. 

SEBORRHEA 

Synon5rms. — Pityriasis;  dandruff;  tinea  furfuracea. 

Definition. — A  functional  disorder  of  the  sebaceous  glands  of 
the  skin,  characterized  by  an  excessive  or  diminished  and  abnormal 
secretion  of  sebaceous  matter,  forming  upon  the  skin  either  as  an 
oily  coating  or  in  crusts  and  scales. 

Varieties. — Seborrhea  oleosa;  seborrhea  sicca. 

Causes. — In  newly  born  infants  an  increased  secretion  of  seba- 
ceous matter — the  vernix  caseosa — is  a  physiological  process. 

The  origin  of  the  disease  is  not  fully  understood,  anemia  being 
a  factor  in  many  cases.  Brunettes  are  more  often  affected  than 
blondes,  and  women  more  frequently  than  men. 

Pathology. — Seborrhea  is  a  functional  derangement  of  the  seba- 
ceous glands;  if  it  be  allowed  to  become  very  chronic,  there  occurs 
atrophy  of  the  glands  and  follicles. 

Symptoms. — The  affection  may  occur  upon  any  portion  of  the 
body  its  most  frequent  seat  being,  however,  the  scalp   {seborrhea 


752  SEBOREHEA 

capitis  or  pityriasis  capitis),  and  next  in  frequency  the  face  (seborrhea 
faciei) . 

Seborrhea  oleosa  appears  as  an  oily,  greasy  coating  upon  the  skin, 
without  hyperemia,  and  not  attended  with  itching.  The  secretion 
is  of  an  oily  character,  the  quantity  at  times  being  so  great  as  to 
collect  in  minute  drops  of  a  clear,  yellowish  fluid  upon  the  surface. 
The  most  common  seat  for  this  variety  is  the  face — seborrhea  faciei — 
and  nose — seborrhea  nasi. 

Seborrhea  sicca  consists  in  the  formation  of  dry,  more  or  less 
greasy,  masses  of  scales  or  crusts  of  a  grayish,  yellowish,  or  brownish- 
yellow  color,  having  a  strong  tendency  to  adhere  to  the  skin,  and 
attended  with  decided  itching.  Occurring  upon  the  scalp — seborrhea 
capitis — it  is  a  frequent  source  of  premature  baldness. 

Diagnosis. — Seborrhea  capitis  may  be  mistaken  for  dry  eczema, 
but  the  former  is  always  a  dry  disease,  while  in  eczema  moisture 
has  occurred  at  some  period  of  the  affection.  The  scales  in  seborrhea 
are  very  abundant  and  pale;  in  eczema  the  scales  are  scanty  and  red- 
dish, the  parts  irritated,  infiltrated,  and  thickened. 

Seborrhea  sicca  and  psoriasis  have  many  points  of  resemblance 
whether  occurring  on  the  scalp  or  on  the  body.  In  seborrhea  the 
scales  are  minute  or  caked,  grayish  or  yellowish  in  color,  of  an  unc- 
tuous feel,  and  usually  uniformly  diffused.  In  psoriasis  the  scales 
are  very  dry,  abundant,  thick,  white,  irregularly  dispersed,  with 
intervening  healthy  skin,  and  the  surface  beneath  the  scales  is  always 
reddish  and  inflamed.  The  clinical  histories  of  each  are  entirely 
different. 

Prognosis. — If  properly  treated,  favorable,  although  the  affection 
is  obstinate  to  eradicate.  Its  tendency  to  produce  premature  loss 
of  hair  when  occurring  on  the  scalp  should  be  borne  in  mind. 

Treatment. — The  condition  of  the  general  health  should  receive 
attention.  The  secretions  should  be  regulated.  Anemia,  chlorosis, 
gastrointestinal  disorders,  and  other  general  conditions  should  re- 
ceive appropriate  treatment.  Iron,  arsenic,  ichthyol,  and  calcium 
sulphide,  internally,  are  of  especial  value  in  this  condition.  The 
following  formula  of  Erasmus  Wilson  is  often  of  benefit : 

I^.     Vini  ferri f  Bjss  45  c.c. 

Syr.  simplicis 

Liq.  potassii  arsenit aa  f  3ij  aa         8  c.c. 

Aquae  destil f  §ij  60  c.c. 

M.  S. — Teaspoonful  three  times  a  day,  well  diluted. 


SEBORRHEA  753 

Local  treatment  is  of  greatest  importance.  In  seborrhea  of  the 
scalp  the  scales  and  crusts  should  first  be  removed  by  olive  oil,  cod- 
liver  oil,  or  lard  applied  at  night  and  the  head  covered  with  a  flannel 
or  other  cap.  A  mixture  of  boroglycerin  (5ij)  and  rose  water 
(§  viij)  applied  on  gauze  is  also  of  value  in  this  connection.  As  soon 
as  the  crusts  are  well  soaked,  they  should  be  removed  by  washing 
with  soap  and  warm  water,  or  equal  parts  of  soap,  glycerin,  and 
water,  or  the  following: 

I^.     Tinct.  sapo.  mollis. . f  Biv  120  c.c. 

Spt.  vini  rect ' f  gij  60  c.c. 

Solve  et  filtra. 

M.  S. — Dilute  and  use  as  a  soap-wash  or  shampoo. 
After  removing  the  crusts,  the  scalp  should  be  washed  with  warm 
water  and  carefully  dried.     In  most  cases,  an  ointment  such  as  the 
following,  rubbed  well  into  the  roots  of  the  hair,  is  very  beneficial : 

I^.     Sulph.  praecip 5j  4-0  gm. 

Acid  salicyl gr.  x  0.6  gm. 

Petrolat 5  j  32 .  o  gm. 

M.  S. — Part  the  hair  and  apply  directly  to  the  scalp  every 
night. 
Or— 

I^.     Hydrarg,  ammoniat gr,  xx  1.3  gm. 

Lanolin 5ij  8.0  gm. 

Petrolat 5vj  24.0  gm. 

M.  S. — Apply  locally  as  directed. 
The   boroglycerid   mixture    mentioned   above    or   the   following 
combination  is  useful  for  dandruff: 

I^.     Acid,  boric 5j  4  gm. 

Alcohol  (50  per  cent.) §iv  120  gm. 

M.  S.— Apply  locally. 
Or— 

I^.     Acid,  carbol 5ss  to  5j  2  to  4  gm. 

01.  amygdalae f  3iv  15  c.c. 

01.  limonis f5i  4  c.c, 

Aq.  destillat q.  s.  ad  f  §ij  60     •  c.c. 

M.  S. — Apply  locally  after  washing    (Van   Harlingen). 
Or— 

I^.     Resorcin 5ss  to  5j        2  to  4  gm. 

Ung.  aquas  rosae Bj  32  gm. 

M.  S.— Apply  locally. 
48 


12 

c.c. 

12 

c.c. 

8 

c.c. 

6o 

c.c. 

30 

c.c. 

4gm 

8 

gm 

32  gm 

754  PRURITUS 

Or— 

I^.     Resorcin 5ss  2.0  gm. 

Olei.  ricini lUxv  i .  o  c.c. 

Alcohol f  5iij  90.0  c.c. 

M.  S. — Apply  locally  by  means  of  a  medicine  dropper. 
(For  brunettes  only). 
Or— 

I^.     Tinct.  cantharidis f  Siij 

Tinct.  capsici f  3iij 

01.  ricini ,   f  5ij 

Alcoholis f  5  ij 

Spt.  rosmarini f§j 

M.  S. — Apply  locally  (Duhring). 
Or— 

I^.     Bismuthi  subnitratis 5j 

Ung.  hydrargyri  ammoniat    5ij 

Ung.  aquae  rosae ad    5 3  ^'^ 

M. 
Seborrhea  elsewhere  is  treated  in  a  similar  manner,  modifying  the 
applications  according  to  the  individual  needs  of  the  case. 

DISORDER  OF  SENSATION 

PRURITUS 

A  functional  disorder  of  the  skin  characterized  essentially  by  itching 
without  structural  alterations  or  obvious  cause.  Itching  due  to 
other  disturbances  is  termed  symptomatic  and  its  relief  depends  upon 
the  removability  of  the  underlying  condition.  Primary  pruritus 
is  difficult  to  permanently  cure  but  relief  may  be  afforded  by  the  use 
of  applications  containing  carbolic  acid,  menthol,  thymol,  chloral- 
camphor,  liquor  carbonis  detergens,  and  similar  antipruritics.  Idio- 
pathic pruritus  is  by  no  means  common  and  a  careful  search  will 
usually  detect  some  underlying  condition  for  the  apparent  primary 
itching,  removal  of  which  relieves  the  pruritus.  Frequently,  cases 
without  obvious  cause  come  under  observation  which  require  symp- 
tomatic treatment  while  a  search  is  being  made  for  the  underlying 
condition.     For  such  cases  the  following  formulas  are  applicable : 

I^.     Acid,  carbol 5ij  8  c.c. 

Glycerin 5ij  8  c.c. 

Aquae Oj  480  c.c. 

M.  S. — Poison,  apply  locally  as  directed. 


PRURITUS  755 

Or— 

I^.     Liq.  carbonis  cleterg •  •    Sij  8  c.c. 

Aquae Sviij  240  c.c. 

M.  S. — Apply  locally. 
Or— 

I^.     Thymol 5ij  8  gm. 

Liq.  potass 5j  4  c.c. 

Glycerin 5iij  12  c.c. 

Aquae 5 viij  240  c.c. 

M.  S. — Apply  locally  (Crocker). 
Or— 

I^.     Resorcin 5ss  2  gm. 

Glycerin 5j  4  c.c. 

Liq.  calcis f5iv  120  c.c. 

M.  S. — Apply  locally. 
Generalized  itching  nearly  always  suggests  infection  by  some  of  the 
animal  parasites,  especially  scabies.     When  the  scratch-marks  are 
localized  for  the  most  part  to  the  flexor  surfaces  it  is  a  good  plan  to 
advise  the  following : 

I^.     Sulph.  praecip. 

Betanaphthol aa    5ss  aa     2  gm. 

Petrolat §j  32  gm. 

M.  S. — Apply  to  all  parts  of  the  body,  excepting  the  head 
and  face,  for  four  nights;  then  follow  with  a  bath.  Should 
the  itching  then  continue,  do  not  repeat  the  treatment  at  once, 
but  instead  use  a  carbolic-acid  lotion  for  a  week  or  ten  days 
and  then  return  to  the  first  treatment  if  necessary. 

Menthol  is  frequently  of  value  in  relieving  itching,  especially  when 
incorporated  in  an  ointment  or  paste. 

I^.     Menthol gr.  viij  o .  48  gm. 

Pulv.  amyli 

Pulv.  zinci  oxidi aa    5ij  8.0    gm, 

Petrolat 5iv  16.0    gm. 

M.  S.— Apply  locally. 
Brocq  advises  the  following  formulas  for  this  condition: 

I^.     Resorcin gr.  iv  0.25  gm. 

Hydrarg.  chlorid.  mit gr.  xij  o. 75  gm. 

Zinci  oxidi gr.  xxx  2  .  o    gm. 

Petrolat 5v  20.0    gm, 

M.     Ft.  ung. 

S. — Apply  locally. 


756  *  PRURITUS 

I^.     Menthol gr.  iij  0.2    gm. 

Acidi  carbolici gr.  iv  0.25  gm. 

Acidi  salicyli 5ss  2.0    gm. 

Zinci  oxidi 3jss  6.0    gm. 

Liq.  petrolat 5j  32.0    gm. 

M.     Ft.  ung. 

S. — Apply  locally. 

Pruritus  ani  is  perhaps  the  most  distressing  form  of  this  disease  and 
for  its  permanent  relief  most  careful  attention  must  be  given  to  the 
most  minute  details  of  the  case.  The  following  formulas  are  recom- 
mended for  relief  of  the  itching : 

I^.     Hydrarg.  ammoniat gr.  xx  1.2  gm. 

Adipis  benzoinat §  j  32 .0  gm. 

M.  S. — Apply  locally  (Crocker). 

^.     Menthol, 
Chloral, 

Camphor aa  gr.  v  0.3  gm. 

Petrolat §ss  16.0  gm. 

M.  S. — Apply  locally. 

I^.     Cocain.  hydrochlorid gr.  xv  I  gm. 

Bismuth,  subnitrat gr.  xxx  2  gm. 

Lanolin 3 v  20  gm. 

M.  S. — Apply  locally. 

When  complicated  with  hemorrhoids,  the  following  is  often  of 
value : 

I^.     Pluidext.  hamamelidis 5viij  30.0  c.c. 

Ext.  hydrastis, 

Ergotin aa  5xv  60 . o  c.c. 

Tinct.  benzoin 5xv  60.0  c.c. 

Olei  olivse 5viij  30 .  o  c.c. 

Acid,  carbol gr.  xxiij  i .  5  c.c. 

M.  S. — For  external  use. 

Malcolm  Morris  speaks  favorably  of  the  following  combinations 
in  the  treatment  of  pruritus  ani: 

I^.     Acidi  carbolici TTtxx  i  .2  c.c. 

Cocain.  hydrochlorid gr.  x  0.6  gm. 

Vaselin 5  j  32 .  o  gm. 

M.     Ft.  ung. 

S. — Apply  locally. 


PRURITUS  757 

I^.     Ung.  picis  liquidae 5j  4.0  gm. 

Bismuthi  subnitratis gr.  xx  1.2  gm. 

Adipis q.  s.  ad   5j  32.0  gm. 

M.     Ft.  ung. 

S. — Apply  locally. 

Laplace  advises  the  following  formula  for  certain  cases  of  anal 
itching: 

I^.     Hydrarg.  chlorid.  corrosiv  .  gr.  ij  0.12  gm. 

Acid,  hydrochlor TTlx  o.  12  c.c. 

Aquae f 5viij  240.0    c.c. 

M.  S. — Apply  locally. 


INDEX 


Abdominal  aorta,  aneurysm  of,  441 

dropsy,  309 

typhus,  14 
Abnormal  pulsations,  383 

states  of  the  blood,  359 
Abscess,  cerebral,  557,  561 

of  the  brain,  557,  561 

of  the  heart,  422 

of  the  liver,  286 

of  the  lung,  136 

perinephritic,  345 

tonsillar,  209 
Absent  respiration,  457 
Acarus  scabiei,  717 
Acetic  acid,  tests  for,  218 
Acetone  in  the  urine,  321 
Achorion  Schoenleinii,  715 
Achylia  gastrica,  223 
Acid,  acetic,  218 

butyric,  217 

dyspepsia,  241 

lactic,  217 
Acidity    of    the    gastric    contents, 

217 
Acne,  688 

artificialis,  690 

atrophica,  689 

cachecticorum,  689 

hypertrophica,  690 

indurata,  689 

papulosa,  689 

punctata,  689 
albida,  734 
nigra,  732 

pustulosa,  689 

rosacea,  693 

tubercula,  689 

vulgaris,  688 
Acromegaly,  382 
Action  of  heart,  386 
Addison's  disease,  376 

keloid,  738 
Adherent  pericardium,  397 
Adhesive  pericarditis,  397 


216, 


After-sensations,  528 
Agraphia,  562 
Ague,  40 

fever  and,  40 
Air  in  the  pleural  cavity,  522 
Albinism,  737 
Albumin  in  the  urine,  317 
Albuminoid  liver,  292 
Albuminuria,  chronic,  330 
Alcohol,  test  for,  218 
Alcoholic  dementia,  650 

paralysis,  601 

pneumonia,  140 
Alcoholism,  185 
Alexia,  542,  563 
Alibert,  keloid  of,  740 
Allen's  starvation  treatment  of   diabetes 

mellitus,  180 
Alopecia,  738 

areata,  739 

universalis,  739 
Alternate  hemiplegia,  549 
Alternating  insanity,  639 
Alvine  flux,  249 
Amebic  dysentery,  112 
American  disease,  the,  623 
Ammonio-magnesium  phosphate,  314 
Ammonium  urate,  315 
Amnesia,  542 

verbal,  563 
Amnesic  aphasia,  562 
Amoeba  coli,  112 
Amphoric  note,  452 

respiration,  459  , 

voice,  463 
Amygdalitis,  209 
Amyloid  kidney,  338 

liver,  292 

reaction,  292,  339 
Amyotrophic  lateral  sclerosis,  588 

paralysis,  597 
Anachlorhydria,  216 
Analgesia,  528 
Anasarca,  392 


759 


760 


INDEX 


Anemia,  361 

cerebral,  54s 

essential,  365 

idiopathic,  365 

lymptiatic,  370 

of  the  skin,  653 

partial  cerebral,  553 

primary,  361 

progressive  pernicious,  365 

secondary,  361 

splenic,  376 

tunnel,  280 
Anemic  murmurs,  387 
Anesthesia,  527 

of  the  skin,  527 
Aneurysm  of  the  abdominal  aorta,  441 

of  the  aorta,  437 

of  the  aortic  arch,  438 

of  the  thoracic  aorta,  441 
Angina,  chronic,  208 

Ludovici,  204 

Ludwig's,  204 

membranous,  77 

pectoris,  433 

simple,  207 

sine  dolore,  434 

Vincent's,  86 
Anginoid  scarlet  fever,  57.58 
Angioneurotic  edema,  660 
Anhydremia,  360 
Anidrosis,  748 
Ankle-clonus,  526 
Ankylostoma   duodenale,    277,    278,    279, 

280 
Ankylostomiasis,  280,  282 
Anopheles,  40,  41,  44,  46 
Anterior  poliomyelitis,  acute,  34 
Anterolateral  sclerosis,  588 
Anthrax,  125 

benigna,  704 

edema,  malignant,  125 

intestinal,  125 
Anuria,  312 

Aorta,  aneurysm  of,  437 
Aortic  insufficiency,  404 

obstruction,  411 

regurgitation,  404 

stenosis,  407,  411 
Aphasia,  542,  562 

amnesic,  562 

ataxic,  562 

motor,  563 
Aphthae,  201 
Aphthous  fever,  88 

stomatitis-,  200 


Apoplexy,  547 

serous,  570 
Appendicitis,  264,  272 
Apraxia,  542 
Apyretic  pneumonia,  140 
Arachnitis,  535 
Argyll-Robertson  pupil,  531 
Argyria,  724 
Arm- jerk,  527 
Arrhythmia,  431 

cordis,  431 
Arteries,  diseases  of  the,  435 
Arteriocapillary  fibrosis,  435 
Arteriosclerosis,  337.  435 
Arthritis  deformans,  169 

rheumatoid,  169 
Arthropathies,  530 

tabetic,  591 
Articular  rheumatism,  acute,  129 

rheumatism,  chronic,  166 
Artisan's  cramp,  625 
Ascaris  lumbricoides,  277,  279,  281 
Ascending  paralysis,  acute,  587 
Ascites,  309 
Asiatic  cholera,  lOS 
Aspiration  pneumonia,  140 
Astereognosis,  529 
Asthma,  500 

bronchial,  500 

hay,  497 

spasmodic,  500 

thymic,  480 
Ataxia,  Friedreich's,  597 

hereditary,  596 

locomotor,  589,  597 
Ataxic  aphasia,  562 

gait,  525 

paraplegia,  593.  597 
hereditary,  596 
Atheroma,  435.  735 
Athetoid  movements,  525 
Atonic  dyspepsia,  241 

Atrophic  cirrhosis  of  the  liver,   289,  290, 
291 

paralysis  of  children,  34 

rhinitis,  471 
Atrophies  of  the  skin,  737 
Atrophy,  acute  yellow,  287 

chronic  spinal  muscular,  584 

lipomatous  muscular,  586 

of  the  liver,  287 

of  the  muscles,  529 

of  the  nails,  738 

optic,  531 

progressive  muscular,  584,  597 


INDEX 


761 


Auditory  center,  542 

vertigo,  564 
Aura  epileptica,  615 
Aural  vertigo,  564 
Auscultation,  385,  453 
Auscultatory  percussion,  453 
Automatism,  postepileptic,  616 
Autumnal  catarrh,  497 

fever,  14 
Axis-cylinder  process,  540 

Babinski's  reflex,  527 
Baccelli's  sign,  520 
Bacillary  dysentery,  112 
Bacillus  anthracis,  125 

coli  communis,  264,  340 

comma,  105 

dysenteriae,  112,  258 

epilepticus,  6 IS 

fusiform,  86  ^ 

Klebs-Loeffler,  77,  81 

Koch's,  105 

lepras,  163 

mallei,  87 

of  Bordet-Gengou,  126 

of  diphtheria,  77,  81 

of  Eberth,  14,  20 

of  Pfeiffer,  10 

of  Shiga,  112,  258 

pestis,  120 

tetani,  121 

tuberculosis,  146,  4671  743 

typhi  exanthematici,  28 
Baldness,  738 
Banti's  disease,  376 
Barbers'  itch,  712 
Barlow's  disease,  373 
Basedow's  disease,  377 
Basilar  meningitis,  538 
Basophiles,  358 
Bell's  palsy,  610 
Bends,  the,  198 
Beri-beri,  604 
Bile  in  urine,  321 
Biliary  calculi,  298 

passages,  diseases  of,  296 
Bilious  cholera,  256 

fever,  47 

headache,  567 

malignant  fever,  s  i 

pneumonia,  139 

remittent  fever,  47 
Biliousness,  284 
Black  death,  119 

measles,  63 


Black  stools,  249 

vomit,  SI 
Black-heads,  732 
Black  water  fever,  50 
Bladder,  catarrh  of,  351 

diseases  of,  326 
Blebs,  653 

Bleeder's  disease,  371 
Blood,  abnormal  states  of  the,  359 

casts,  324 

currents,  388 

diseases  of,  354 

examination  of,  354 

in  chlorosis,  363 

in  leukocythemia,  369 

in  pernicious  anemia,  366 

in  urine,  320 

microscopical  examination  of  the,  358 

murmurs,  387 

occult,  237 
Blood-pressure,  391 
Bloody  flux,  112 

stools,  2S0 
Boas'  test,  216 

test- meal,  21s 
Boettger's  test,  318 
Boils,  703 

Bordet-Gengou,  bacillus  of,  126 
Bothriocephalus  latus,  274 
Bowels,  inflammation  of,  252 
Brachycaria,  430 
Bradycardia,  390,  430 
Brain,  abscess  of,  557,  561 

congestion  of,  S43 

lesions  of,  543 
Brand  bath,  24 
Break-bone  fever,  ss 
Breast-pang,  433 
Breath,  foul,  206 

Bright's  disease,  327,  330,  333.  338 
Bromidrosis,  746 

pedum,  746 
Bronchial  asthma,  soo 

catarrh,  485 
acute,  48s 
chronic,  489 

dilatation,  490 

fremitus,  448 

hemorrhage,  S07 

r&les,  460 

respiration,  458 

tubes,  diseases  of,  48s 

whisper,  463 
Bronchiectasis,  490 
Bronchitis,  acute,  485 


762 


INDEX 


Bronchitis,  capillary,  512 

chronic,  489 

fetid,  490 

fibrinous,  495 

membranous,  495 

plastic,  495 

secondary,  489 
Bronchophony, 463 
Bronchopneumonia,  487,  512 
Broncho-pulmonary  hemorrhage,  507 
Bronchorrhagia,  507 
Bronchorrhea,  490 
Bronzed-skin  disease,  376 
Bruce's  micrococcus,  39 
Brudzinski's  sign,  32 
Bubonic  plague,  119 
Bulbar  paralysis,  582 
Btillae,  653 
Butyric  acid,  tests  for,  217 

Cachexia,  malarial,  50 

strumipriva,  379 
Caisson  disease,  198 
Calcium  oxalate,  315,  316 
Calcvili,  biliary,  298 

cutaneous,  734 

hepatic,  298 

pancreatic,  305 

renal,  341 
Callositas,  726 
Callosity,  726 
Callus,  726 
Calvities,  738 
Calmette's  reaction,  155 
Cancer,  gastric,  231 

hepatic,  294 

of  the  esophagus,  213 

of  the  liver,  294 

of  the  pancreas,  304 

of  the  stomach,  231  , 

Cancrum  oris,  202 
Canities,  738 
Canker,  200 

Capillary  bronchitis,  512 
Capsular  hemorrhage,  549 
Caput  Medusae,  290 
Carbuncle,  704 
Carbunculus,  704 
Carcinoma,  gastric,  231 

of  the  liver,  294 

of  the  stomach,  231 
Cardiac  murmurs,  387 
Cardialgia,  238 
Cardiosclerosis,  423 
Carditis,  422 


Carditis,  chronic,  423 
Carphologia,  18 
Caseous  phthisis,  149 

pneumonia,  149 
Casts,  324 
Catalepsy,  531 
Catarrh,  autumnal,  497 

bronchial,  485,  489 

chronic  gastric,  223 
nasal,  471 

dry,  490 

epidemic,  10 

gastric,  219 

intestinal,  252 

mucous,  490 

of  the  bladder,  351 

of  the  rectum,  268 
Catarrhal  appendicitis,  264 

croup,  77,  479 

dysentery,  112 

enteritis,  252 

fever,  10 

laryngitis,  474 

nephritis,  326 

pharyngitis,  207 

phthisis,  149 

pneumonia,  149,  5 12 

stomatitis,  199 
Causalgia,  529 
Cavernous  rS,les,  461 

respiration,  458 
Celluhtis  of  the  neck,  204 
Centers,  cerebral,  542 
Centrum  ovale  hemorrhage,  549 
Cephalodynia,  167,  168 
Cerebellar  hemorrhage,  549 
Cerebral  abscess,  557.  561 

anemia,  545.  553 

apoplexy,  547 

congestion,  543 

embolism,  553 

fever,  535 

hemorrhage,  547.  549 

hyperemia,  543 

localization,  541,  549 

membranes,  532 
diseases  of,  532 

sclerosis,  594 

softening,  553 

symptoms  in  cardiac  disease,  392 

thrombosis,  553 

tumors,  559.  S6i 

vessels,  occlusion  of,  553 
Cerebrospinal  fever,  30 

meningitis,  epidemic,  30 


INDEX 


763 


Cerebrospinal  sclerosis,  594 
Cerebrum,  diseases  of,  540 

microscopical  anatomy  of,  540 
Cervico-brachial  neuralgia,  607 
Cervicodynia,  168 
Cervico-occipital  neuralgia,  607 
Cestodes,  273 
Charbon,  125 

Charcot-Leyden  crystals,  467 
Charcot's  joints,  591 
Cheiropompholyx,  685 
Cheloid,  740 
Chest  divisions,  442 
Chest-sounds  in  health,  454 
Cheyne-Stokes  respiration,  428,  530 
Chicken-pox,  73 
Child-crowing,  480 
Children,  atrophic  paralysis  of,  34 

essential  paralysis  of,  34 

pneumonia  in,  140 
Chill,  congestive,  48 
Chills  and  fever,  40 
Chiragra,  172 
Chloasma,  724 

uterinum,  725 
Chlorides,  316 
Chlorosis,  362 

Egyptian,  280 
Choked  disk,  531 

Cholecystitis,  acute  infectious,  301 
Cholelithiasis,  298 
Cholera,  105 

Asiatic,  105 

asphyxia,  108 

bilious,  256 

English,  256 

epidemic,  105 

infantum,  262 

malignant,  105 

morbus,  256 

nostras,  256 

sicca,  108 

sporadic,  256 

typhoid,  IDS 
Choleriform  diarrhea,  262 
Cholerine,  107 
Cholesterin,  317,  318 
Chorea,  613 

Huntington's,  613 

Sydenham's,  613 
Choreiform  movements,  525 
Chromidrosis,  746 
Chromophytosis,  714 
Chvostek's  symptom,  381 
Circular  insanity,  639 


Circulatory  system,  diseases  of,  382 
Cirrhosis  of  the  liver,  289,  295 

of  the  lungs,  156,  516 
Cirrhotic  kidney,  333,  336 
Classification  of  insanity,  628 
Clavus,  621,  727 
Clergyman's  sore  throat,  208 
Clinical  history,  definition  of,  2 
Coating  of  the  tongue,  204 
Cog-wheel  respiration,  457 
Cold  in  the  head,  468 
Cold  on  the  chest,  485 
Cold  sore,  685 

Coleman's  high  calorie  diet,  24 
Colic,  hepatic,  298 

intestinal,  246 

stomachic,  238 
CoUes'  law,  89 
Color  index,  358 
Coma,  530 

diabetic,  185 

uremic,  345 
Combined  lateral  and  posterior  sclerosis, 

593 
Comedo,  732 
Comma  bacillus,  lOS 
Compensation,  cardiac,  403 
Compensatory  hypertrophy,  403 
Concentric  hypertrophy  (cardiac),  417 
Confluent  small-pox,  68 
Congenital  hydrocephalus,  571 
Congestion,  hypostatic,  509 

of  the  brain,  543 

of  the  kidneys,  326 

of  the  liver,  284 

of  the  lungs,  509 

spinal,  573 
Congestive  chill,  48 

fever,  48 
Conjugate  deviation  of  the  eyes,  531 
Consciousness,  disturbances  of,  530 
Constipation,  247 

of  infants,  249 
Constitutional  diseases,  166 
Consumption,  152 

galloping,  146 

throat,  483 
Contagious  disease,  2 
Continued  fever,  6,  9 
Contracted  kidney,  333,  336 
Convulsions,  524 

uremic,  34s 
Cor  bovinum,  405,  417 
Corrigan's  disease,  156 

hammer,  189 


764 


INDEX 


Corrigan's  pulse,  391,  405 

sign,  439 
Corn,  727 
Corona  Veneris,  93 
Corset-liver,  283 
Cortical  hemorrhage,  549 
Coryza,  acute,  468 

chronic,  471 
Coster's  paste,  711 
Costiveness,  247 
Cough,  465 

winter,  489 
Coup-de-soleil,  195 
Cow-pox,  70 
Cracked-pot  sound,  452 
Cramp,  artisan's  625 
Cranio-tabes,  103 
Crepitant  r^le,  461 
Cretinism,  379 
Crisis,  definition  of,  4,  6 

of  locomotor  ataxia,  591 
Crossed  hemiplegia,  549 
Croup,  catarrhal,  77,  479 
false,  77,  479 
membranous,  77 
spasmodic,  77,  479 
true,  77 
Croupous  dysentery,  112 
enteritis,  255 
nephritis,  327,  330,  336 
pneumonia,  134 
stomatitis,  200 
Crus  cerebri  hemorrhage,  549 
Crusta  lactea,  663 
Culex,  41 

fatigans,  56 
Cuniculus,  718 
Curschmann's  spirals,  467 
Cutaneous  calculi,  734 

reflexes,  526 
Cyanosis,  392 
Cyclical  insanity,  639 
Cylindroids,  325 
Cysticercus  bovis,  274 

cellulosae,  274 
Cystin,  316,  317 
Cystitis,  351 
Cysts  of  the  pancreas,  304 

sebaceous,  735 
Cytoryctes  vaccinias,  70 
variolae,  66 

Dancer's  cramp,  625 
Dandruff,  751 
Dandy  fever,  55 


Davy's  test  for  urea,  313 
Deafness,  532 
Death,  black,  119 

causes  of,  4 
Decubitus,  530 
Degeneration,  fatty,  of  the  heart,  426 

of  the  muscles,  529 

reactions  of,  35    * 
Degenerative  neuritis,  601 
Delayed  conduction,  528 
Delirium,  627 

tremens,  i8s,  186,  190 
Delusion,  627,  641 
Delusional  insanity,  641 

mania,  641 

melancholia,  641 
Dementia,  648 

apoplectica,  650 

choreica,  650 

epileptica,  637,  650 

paralytica,  650 

paretic,  644 

senilis,  651 

syphilitica,  651 

toxica,  651 
Demodex  foUiculorum,  733 
Dengue,  54,  55 
Depression  of  spirits,  629 
Dermatitis,  700 

calorica,  700 

exfoliativa,  702 

factitia,  702 

herpetiformis,  682 

medicamentosa,  701 

traumatica,  700 

venenata,  701 
Desmoid  reaction,  Sahli's,  218 
Desquamative  nephritis,  acute,  327 
Diabetic  coma,  185 
Diabetes  insipidus,  183 

mellitus,  176 
Diacetic  acid,  322 

Diagnostic  technique  (stomach),  214 
Diarrhea,  249 

acute,  250,  252 

choleriform,  262 

chronic,  250,  252 

inflammatory,  258 
Diathesis,  2 

hemorrhagic,  371 
Diazo-reaction,  20,  322 
Dibothriocephalus  latus,  273.  274.  275 
Dicrotic  pulse,  390 
Dietl's  crises,  35 
Diffused  pericarditis,  393 


INDEX 


765 


Digestive  system,  diseases  of,  198 
Dilated  hypertrophy  (cardiac),  417 
Dilatation,  bronchial,  490 

gastric,  234 

of  the  heart,  419 

of  the  stomach,  234 
Diminished  respiration,  457 
Diphtheria,  77 

antitoxin,  82 

carriers,  78 

laryngeal,  77,  85 

pseudo,  77 
Diphtheritic  dysentery,  112 

endocarditis,  401 

enteritis,  255 

paralysis,  80 
Diphtheroid,  77 
Diplegia,  524 
Diplococcus,  Fraenkel's,  134 

intracellularis  meningitidis,  30,  31 

pneumoniae,  134 
Dipsomania,  185,  187,  192 
Discrete  small-pox,  66 
Disease,  or  diseases: 

acute,  3 

Addison's,  376 

American,  the,  623 

Banti's,  376 

Barlow's,  373 

Basedow's,  377 

bleeders',  371 

Bright's,  327,  330,  333,  338 

bronzed-skin,  376 

caisson,  198 

chronic,  3 

constitutional,  166 

contagious,  2 

Corrigan's,  156 

definition  of,  I 

Duhring's,  682 

endemic,  2 

epidemic,  2 

fish-skin,  728 

foot  and  mouth,  88 

Friedreich's,  596 

general  nervous,  613 

Graves',  377 

Guinea- worm,  282 

hide-bound,  737 

Hodgkin's,  370 

hook-worm,  280 

infectious,  2,  5 

Leishman-Donovan,  119 

M^ni^re's,  564 

mental,  627 


Disease,  nervous,  general,  613 

of  the  arteries,  435 

of  the  bile  passages,  296 

of  the  bladder,  326 

of  the  blood,  354 

of  the  bronchial  tubes,  48,=; 

of  the  cerebral  membranes,  532 

of  the  cerebrum,  540 

of  the  circulatory  system,  382 

of  the  digestive  system,  198 

of  the  ductless  glands,  354 

of  the  endocardium,  399 

of  the  esophagus,  212 

of  the  gall  bladder,  296 

of  the  intestines,  243 

of  the  kidneys,  326 

of  the  larynx,  474 

of  the  liver,  282 

of  the  lungs,  504 

of  the  mouth,  198 

of  the  myocardium,  417 

of  the  nasal  passages,  468 

of  the  nerves,  599 

of  the  nervous  system,  523,  532 

of  the  pancreas,  302 

of  the  pericardium,  393 

of  the  peritoneum,  305 

of  the  pharynx,  207 

of  the  pleura,  516 

of  the  respiratory  system,  442 

of  the  skin,  652 

of  the  spinal  cord,  573 

of  the  stomach,  214 

of  the  tongue,  204 

of  the  tonsils,  207 

of  the  urinary  organs,  311 

Osier's,  371 

pandemic,  2 

parasitic,  of  the  skin,  707 

parasyphilitic,  91 

Parkinson's,  626 

Parry's,  377 

Quincke's,  660 

Raynaud's,  624 

Schoenlein's,  375 

sporadic,  2 

subacute,  3 

valvular,  402 

Vaquez's,  371 

wool-sorter's,  125 
Disorders  of  secretion  (skin),  745 

of  sensation,  754 
Disseminated  neuritis,  601,  604 

sclerosis,  594 
Disturbances  of  consciousness,  530 


766 


INDEX 


Distuxbances  of  special  senses,  531 
Divers'  paralysis,  198 
Dizziness,  564 
Dobell's  solution,  60 
Dorsointercostal  neuralgia,  607 
Double  pneumonia,  136,  140 

quartan  fever,  42 
Dracontiasis,  282 
Dracunculus  medinensis,  282 
Dropsy,  392 

abdominal,  309 

of  the  pleura,  521 

pericardial,  398 
Dry  catarrh,  490 

pericarditis,  393 

T^es,  459 
Ductless  glands,  diseases  of,  354 
Duhring's  disease,  682 
Dullness,  452 
Duodenal  ulcer,  227 
Duodenitis,  252 
Dura  mater,  532 

inflammation  of,  533 
Dural  hemorrhage,  549 
Dysentery,  112,  268 

chronic,  114 
Dysesthesia,  529 
Dysidrosis,  685 
Dyspepsia,  224,  240,  241 

acid,  241 

acute,  219 

atonic,  241 

chronic,  223 

intestinal,  243 

nervous,  241 
Dyspnea,  392,  464 

cardiac,  464 

Ear,  disturbances  of,  532 
Eberth,  bacillus  of,  14,  20 
Eccentric  hypertrophy  (cardiac),  41'; 
Ecchymoses,  374 
Echinococcus,  273,  274,  275 

of  the  liver,  293 
Ecstasy,  531,  622 
Ecthyma,  681 
Eczema,  661 

ani,  677 

aurium,  676 

barbae,  675 

capitis,  672 

chronic,  664,  671 

crurum,  680 

erythematosum,  662 

faciei,  674 

fissum,  664 


Eczema,  genitalium,  676 

impetiginosum,  663 

intertrigo,  662,  678 

labiorum,  674 

madidans,  663 

mammarum,  678 

marginatum,  708 

narium,  675 

palmarum,  679 

palpebrarum,  675 

papillomatosum,  664 

papulosum,  662 

plantarum,  679 

pustulosum,  663 

rimosum,  664 

rubrum,  663 

sclerosum,  664 

seborrhoicum,  680 

squamosum,  662,  664 

unguium,  679 

universal,  672 

verrucosum,  664 

vesiculosum,  663 
Edema,  392 

angioneurotic,  660 

malignant  anthrax,  125 

of  the  glottis,  476 

of  the  lungs,  511 

pulmonary,  511 
Edematous  laryngitis,  476 
Egophony,  463 
Egyptian  chlorosis,  280 
Ehrlich's  diazo  reaction,  20,  322 
Elephantiasis,  736 

graecorum,  162 
Embolism,  cerebral,  553 
Emphysema,  504 

senile,  504 

vesicular,  504 
Emphysematous  chest,  446 
Emprosthotonos,  121 
Empyema,  517.  52 1 

of  pericardium,  397 
Encephalitis,  acute,  557 

suppurative,  557 
Endarteritis  chronica  deformans,  435 
Endemic  disease,  2 

multiple  neuritis,  604 
Endocardial  murmurs,  387 
Endocarditis,  acute,  399 

chronic,  402 

diphtheritic,  401 

exudative,  399 

malignant,  401 

mycotic,  401 


INDEX 


767 


Endocarditis,  plastic,  399 

septic,  401 

ulcerative,  401 
Endocardium,  diseases  of,  399 
English  cholera,  256 
Engorgement,  pulmonary,  509 
Enteralgla,  246 
Enteric  fever,  14 
Enteritis,  catarrhal,  252 

croupous,  255 

diphtheritic,  255 

membranous,  255 

pseudomembranous,  255 
Enterocolitis,  258 

ulcerative,  258 
Enteromesenteric  fever,  14 
Enterorrhea,  249 
Eosinophiles,  357 
Eosinophilia,  359 
Ephemeral  fever,  9 
Ephidrosis,  745 
Epidemic  catarrh,  10 

cerebrospinal  fever,  30 
meningitis,  30 

cholera,  105 

diseases,  2 

roseola,  65 

stomatitis,  88 
Epilepsia  gravior,  615 

mitior,  615 
Epilepsy,  615 

Jacksonian,  615 
Epileptic  dementia,  638 

imbecility,  638 

insanity,  637 
Epileptiform  convulsions,  524 
Epithelial  casts,  324 
Epithelioma  of  tongue,  206 
Erb's  type  of  muscular  atrophy,  585 
Eruptive  fevers,  8,  9 
Erysipelas,  73 

ambulans,  74 

idiopathic,  74 

phlegmonous,  74 
Erythema  caloricum,  654 

induratum,  656 

intertrigo,  654 

multiforme,  654 

nodosum,  656 

scarlatinoides,  655 

simplex,  654 

solare,  654 

toxic,  654 

traumaticum,  654 

venenatum,  654 


Erythematous  stomatitis,  199 
Erythremia,  371 
Erythromelalgia,  607 
Esbach's  test,  318 
Esophageal  obstruction,  212 
Esophagismus,  212 
Esophagitis,  212 
Esophagus,  cancer  of,  213 

diseases  of,  212 

obstruction  of,  212 
Essential  anemia,  365 

paralysis  of  children,  34 
Estivo-autumnal  fever,  47 

parasite,  42 
Etiology,  definition  of,  i 
Euchlorhydria,  216 
Ewald's  test-meal,  215 
Exaggerated  respiration,  456 
Exanthemata,  9 

table  of,  8 
Exan thematic  typhus,  28 
Exophthalmic  goitre,  377 
Expansion  of  the  chest,  447 
Expiration,  447 

External  examination  of  the  stomach,  214 
Extradural  hemorrhage,  549 
Exudative  endocarditis,  399 
Eye,  disturbances  of,  531 

Facial  paralysis,  610 
False  croup,  77,  479 

measles,  65 
Famine  fever,  38 
Farcy,  87 
Fatty  casts,  325 

heart,  426 

stools,  249 
Favus,  715 

cups,  7 IS 
Febricula,  9 

Febrile  jaundice,  acute,  166 
Febris  recurrens,  38 
Feeble-mindedness,  acquired,  648 
Fehling's  test,  319 
Festinating  gait,  525 
Fetid  bronchitis,  490 

stomatitis,  201 
Fever  or  fevers,  s 

and  ague,  40 

aphthous,  88 

autumnal,  14 

bilious,  47 
malignant,  51 
remittent,  47 

blackwater,  51 


768 


INDEX 


Fever  blisters,  68s 
break-bone,  ss 
catarrhal,  lO 
cerebral,  535 
cerebrospinal,  30 
chills  and,  40 
congestive,  48 
continued,  6,  9 
dandy,  55 
definition  of,  5 
degrees  of,  5 
diurnal  variations  of,  6 
double  quartan,  42 
enteric,  14 
enteromesenteric,  14 
ephemeral,  9 

epidemic  cerebrospinal,  30 
eruptive,  8,  9 
estivo-autumnal,  47 
famine,  38 
gastric,  14,  219 
general  treatment  of,  7 
Gibraltar,  39 
glandular,  164 
hemoglobinuric,  SO 
immunity  in,  9 
incubation  period  of,  7 
intermittent,  6,  44 
jail,  28 
jaundice  in,  9 
lung,  134 

malignant  intermittent,  48 
malarial,  54 

pernicious,  48 
Malta,  39 
marsh,  40,  47 
Mediterranean,  39,  Si 
Neapolitan,  39 
nervous,  14 
paratyphoid,  28 
pernicious  malarial,  48 
petechial,  30 
puking,  165 
putrid,  28 
quartan,  42    ' 
quotidian,  42 
relapsing,  38 
remittent,  6,  47 

bilious,  47 

malaria,  47 

malignant,  48 
rheumatic,  129 
rock,  39 

Rocky  Mountain  spotted,  165 
sailors',  51 


Fever,  scarlet,  s6 

seven-day,  38 

ship,  28 

simple  continued,  9 

spirillum,  38 

splenic,  125 

spotted,  28,  30 

swamp,  40 

tertian,  42 

thermic,  19s 

types  of,  6 

typhoid,  14 

typho-malarial,  21,  47 

typhus,  28 

undulant,  39 

yellow,  SI.  S4 
Fibrinous  bronchitis,  495 

pneumonia,  134 
Fibroid  heart,  423 

phthisis,  156 

pneumonia,  516 
Fibrosis,  arteriocapillary,  435 
Fibrous  myocarditis,  423 
Filaria,  Bancrofti,  279 

medinensis,  282 

noctuma,  279 

sanguinis  hominis,  277,  279,  281,  736 
Filariasis,  281,  282 
Fish-skin  disease,  728 
von  Fleischl's  hemoglobinometer,  35s 
Flint  murmur,  409 
Floating  kidney,  349 

liver,  283 
Flux,  alvine,  249 

bloody,  112 
Focal  symptoms,  S43.  560 
Folie  circulaire,  629,  639 
Follictilar  stomatitis,  200 
Foot  and  mouth  disease,  88 
Foul  breath,  206 
Fowler's  test  for  urea,  313 
Fraenkel's  diplococcus,  134 
Frankel  treatment,  S92 
Freckles,  723 
Fremitus,  447 
French  measles,  65 
Friction  fremitus,  448 

murmurs,  387 
Friedlander's  pneumococcus,  134 
Friedreich's  ataxia,  597 

disease,  596 
Full  pulse,  391 
Functional  affections  of  the  heart,  428 

endocardial  murmurs,  387 

obstruction  of  the  esophagus,  212 


INDEX 


769 


Furuncle,  703 
Furunculosis,    703 
Furunculus,  703 
Fusiform  bacillus,  86 

Gait,  52s 

Gall-bladder,  acute  inflammation  of,    301 

diseases  of,  296 
Gall-stones,  298 
Galloping  consumption,  146 
Gangrene  of  the  lung,  136 
Gangrenous  pancreatitis,  303 

stomatitis,  202 
Gaskell's  bridge,  432 
Gastralgia,  238 
Gastrectasia,  234 
Gastrectasis,  234 
Gastric  cancer,  231 

carcinoma,  231 

catarrh,  219,  223 

dilatation,  234 

fever,  14,  219 

hemorrhage,  236 

indigestion,  240 

insufficiency,  241 

irritation,  241 

ulcer,  227 

vertigo,  565 
Gastritis,  acute,  219 

chronic,  223 

simple,  219 

toxic,  220,  222 
Gastrodynia,  238 
Gastroptosis,  235 
Gastrorrhagia,  236 
General  paralysis  ofthe  insane,  644 

paresis,  644 
Geographical  tongue,  204 
German  measles,  65 
Gibraltar  fever,  39 
Giddiness,  564 
Gin-drinkers'  liver,  289 
Gingivitis,  199 
Glanders,  87 
Glandular  fever,  164 
Globus  hystericus,  620 
Glossitis,  205 

Glosso-labio-pharyngo-laryngeal  paralysis, 

582 
Glossy  skin,  529 
Glottis,  edema  of,  476 

spasm  of,  480 
Glycosuria,  176,  179 
Gmelin's  test  for  bile,  321 
Goitre,  exophthalmic,  377 
49 


Gonagra,  172  * 
Gout,  172 
Gouty  kidney,  333 
Graefe's  sign,  378 
Grand  mal,  le,  615 
Granular  casts,  324,  325 

kidney,  333,  336 

pharyngitis,  208 
Gravel,  341 
Graves'  disease,  377 
Gray  hepatization,  135 
Green  sickness,  362 

stools,  249 
Grip,  10 
Gripes,  246 
Grutum,  734 

Guinea- worm  disease,  282 
Gumma,  90 

Gums,  affections  of  the,  199 
Guenzburg's  test,  216 
Gurgling  rS,le,  461 

Hair,  hypertrophy  of,  73s 
Hallucination,  627,  642 
Hallucinatory  melancholia,  629 
Hammerschlag's  method,  356 
Hard  pulse,  391 
Harsh  respiration,  458 
Hay  asthma,  497 

fever,  497 
Headache,  567 
Heartburn,  240 
Heart,  abscess  of,  422 

action  of,  386 

-block,  432 

dilatation  of,  419 

fatty,  426 

fibroid,  423 

functional  affections  of  the,  428 

hypertrophy  of,  417 

irritable,  428 

murmurs,  387 

neuralgia  of,  433 

palpitation  of  the,  391,  428 

paroxysmal  rapid,  429 

quick,  429 

rapid,  429 

sounds,  38s,  386 
Heat  and  nitric  acid  test  for  albumin,  31! 
Heat  exhaustion,  195 

stroke,  19s 
Heberden's  nodosities,  170 
Heller's  test  for  albumin,  317 

test  for  blood,  321 
Hematemesis,  236 


770 


INDEX 


Hematidrosis,  746 
Hematuria,  320 

malarial,  so 
Hematogenous  jaundice,  297 
Hemianesthesia,  528 
Hemic  murmurs,  387 
Hemichorea,  613 
Hemicrania,  567 
Hemiplegia,  524 
Hemoconien,  358 
Hemoglobin,  355 
Hemoglobinuria,  320 

malarial,  50 
Hemoglobinuric  fever,  so 
Hemophilia,  371 
Hemoptysis,  237,  507 

bronchial,  S07 

bronchopulmonary,  507 
Hemorrhage,  bronchial,  507 

cerebral,  547 

dural,  S49 

gastric,  236 

occult,  237 
Hemorrhagic  diathesis,  371 

icterus,  287 

measles,  63 

pancreatitis,  303 
Hepatic  calculi,  298 

cancer,  294 

colic,  298 
Hepatitis,  acute,  286 

interstitial,  289 

parenchymatous,  286,  287 

suppurative,  286 
Hepatization  in  pneumonia,  13s 
Hereditary  ataxia,  596 

ataxic  paraplegia,  596 

syphilis,  89,  loi 
Herpes  circinatus,  707 

facialis,  686 

gestationis,  682,  686 

labialis,  686 

preputialis,  686 

progenitalis,  686 

simplex,  68s 

tonsurans,  709 
maculosus,  700 

zoster,  604 
Herpetic  stomatitis,  200 
Hidebound  disease,  737 
Hirsuities,  735 
His,  bundle  of,  432 
Hives,  657 

Hob-nailed  liver,  289 
Hodgkin's  disease,  370 


Hook-worm  disease,  280 
Hope's  camphor  mixture,  116,  254 
Horrors,  the,  186 
Host,  273 

intermediate,  273 
Huntington's  chorea,  613 
Hutchinson's  teeth,  102,  199 

triad,  102 
Hyaline  casts,  32s 
Hydatid  cyst  of  the  liver,  293 
Hydremia,  360 
Hydroa,  682 
Hydrocephalic  cry,  S38 
Hydrocephalus,  acute,  S38,  S70 

acquired,  570 

chronic,  571 

congenital,  S7i 

external,  S7i 

internal,  571 
Hydrochloric  acid,  tests  for,  210 
Hydronephrosis,  344 
Hydropericardium,  398 
Hydroperitoneum,  309 
Hydrophobia,  123 
Hydropneumothorax,  522 
Hydrosis,  74s 
Hydrothorax,  S2i 
Hyperacidity,  216 
Hyperchlorhydria,  216 
Hyperemia  cerebral,  543 

of  the  skin,  6S3 

renal,  326 

spinal,  573 
Hyperesthesia,  S27 
Hyperidrosis,  74s 
Hypertrichosis,  73s 

Hypertrophic  cirrhosis  of  the  liver,  289, 
290,  291 

pachymeningitis,  575 
Hyperresonance,  452 
Hypertrophy,  compensatory,  403 

of  the  hair,  735 

of  the  heart,  417 

of  the  nails,  736 

of  the  skin,  723 

of  the  tonsils,  211 

pseudo-muscular,  586 
Hypochlorhydria,  216 
Hypochondriac  melancholia,  629 
Hypochondriasis,  619 
Hypostatic  congestion,  S09 
Hypotonia,  S9i 
Hysteria,  619 
Hystero-epilepsy,  621 
Hy steroidal  convulsions,  524 


INDEX 


771 


Ichthyosis,  728 

hystrix,  729 

lingualis,  206 

nigricans,  729 

simplex,  729 

vera,  728 
Icterus,  296 

hemorrhagic,  287 

neonatorum,  297 
Idiocy,  629 

Idiopathic  anemia,  365 
Idrosis,  745 
Ileocolitis,  252 
Illusion,  627 

Imbecility  with  epilepsy,  637 
Immunity  in  fevers,  9 
Impetigo  contagiosa,  680 
Incipient  phthisis,  152 
Incubation  period  of  fevers,  3,  7 
Indicanuria,  322 
Indigestion,  acute,  243 

chronic,  244 

gastric,  240 

intestinal,  243 
Infantile  meningeal  hemorrhage,  549 

paralysis,  34 

scurvy,  373 

spinal  paralysis,  34 
Infants,  constipation  of,  249 
Infectious  diseases,  2,  5 
Inflammation  of  the  bowels,  252 

of  the  gall-bladder,  301 

of  the  peritoneum,  305 

of  the  skin,  654 

of  the  tongue,  205 
Inflammatory  diarrhea,  258 

rheumatism ,  .129 
Influenza,  10,  487 

Insane,  general  paralysis  of  the,  644 
Insanity,  632 

alternating,  639 

chronic  delusional,  643 

circular,  639 

classification  of,  628 

definition  of,  627,  632 

delusional,  641 

epileptic,  637 

Kahlbaum's,  639 

paralytic,  648 
Insolation,  195 
Inspection,  382,  446 
Inspiration,  447 
Insufficiency,  aortic,  241 

gastric,  241 

mitral,  403 


Insufficiency,  pulmonary,  410 

tricuspid,  406,  409 
Insular  sclerosis,  594 
Intentional  tremor,  595 
Intermediate  host,  273 
Intermittent  fever,  6,  44 
malignant,  48 

pneumonia,  139 

pulse,  390 

tetanus,  380 
Interstitial  appendicitis,  265 

hepatitis,  289 

myocarditis,  chronic,  423 

nephritis,  chronic,  333,  336 

pneumonia,  chronic,  156,  516 
Intestinal  anthrax,  125 

catarrh,  252 

colic,  246 

dyspepsia,  243 

indigestion,  243* 

invagination,  269 

knots,  269 

obstruction,  269,  272 

parasites,  273 

torpor,  247 

trichina,  278 
Intestine,  tuberculous  ulcer  of,  15 

typhoid  ulcer  of,  15 
Intestines,  diseases  of,  243 
Intoxications,  185 
Intracranial  tumor,  559 
Intussusception,  269,  272 
Invagination,  intestinal,  269 
Iodoform  test,  218 
Irregular  pulse,  390,  431 
Irritable  heart,  428 
Irritation,  gastric,  241 
Ischemia,  361 
Itch,  the,  717 
Itch-mite,  717 
Itching,  754 
Ivy  poisoning,  701 

Jacksonian  epilepsy,  615 
Jaflfe's  test  for  indican,  322 
Jail  fever,  28 
Jaundice,  296 

acute  febrile,  166 

catarrhal,  297 

hematogenous,  297 

in  fevers,  9 

malignant,  287 

non-obstructive,  297 
Jaw-jerk,  527 
Johnson's  test  for  albumin,  318 


772  INDEX 

Johnson's  test  for  sugar,  319 
Joint,  Charcot's,  591 

Kahlbaum's  insanity,  639 
Kakk6,  604 
Kala-Azar,  119 
Katatonia,  639 
Keloid,  740 

of  Addison,  738 

of  Alibert,  740 
Keratosis  pilaris,  735 
Kemig's  sign,  31,  32 
Kidney,  amyloid,  338 

cirrhotic,  333,  336 

congestion  of,  326 

contracted,  333,  336 

floating,  349 

gouty,  333 

granular,  333,  336 

inflammation  of,  see  Nephritis. 

lardaceous,  338 

large  white,  330,  336 

movable,  349 

sclerosis  of,  333 

small  red,  333,  336 
white,  336 

stone  in,  341 

surgical,  339 

tuberculosis  of,  345 

wandering,  349 

waxy,  338 
Kidneys,  diseases  of,  326 
Klebs-Loefiler  bacillus,  77,  81 
Koch's  bacillus,  of  cholera,  105 

bacillus  of  tuberculosis,  146 
Koplik's  spots  in  measles,  63 
Knee-jerk,  526 
Knots,  intestinal,  269 
Kummerfeld's  lotion,  692 

La  grippe,  10 
Lab  ferment,  test  for,  218 
Laced-ofE  liver,  283 
Lactic  acid,  tests  for,  217 
Lambert's  treatment  for  narcotic    addic- 
tion, 193 
Landry's  paralysis,  587 
Lardaceous  kidney,  338 

liver,  292 
Large  lymphocyte,  357 

white  kidney,  330,  336 
Laryngeal  diphtheria,  77,  85 

muscles,  paralysis  of,  612 

phthisis,  483 

riles.  460 


Laryngeal  resonance,  455 
Laryngismus  stridulus,  480 
Laryngitis,  acute  catarrhal,   474 

chronic  482 

edematous,  476 

spasmodic,  479,  480 

syphilitic,  483 

tuberculous,  483 
Larynx,  diseases  of,  474 
Lateral  and  posterior  sclerosis,    combined, 

593 
Lateral  sclerosis,  597 

amyotrophic,  588 
primary,  588 
Laveran's  Plasmodium,  40 
Law  of  parallelism,  130 
Legal's  test  for.  acetone,  322 
Leichtenstern's     pulmono-hepatic     angle, 

214 
Leishman- Donovan  body,  119 

disease,  119 
Leishmaniasis,  119 
Lentigo,  723 
Lepra,  696 
Leprosy,  162 
Leptomeningitis,  533 

acute,  535 

spinal,  576 
Lesions,  definition  of,  i 

of  the  skin,  652 
Leube  Riegel  test-meal,  215 
Leucin,  317 
Leukemia,  367 

Leukocytes,  polynuclear,  357 
Leukocythemia,  367 
Leukocytosis,  359 
Leukoderma,  737 
Leukopenia,  360 
Leukoplakia,  204 

buccalis,  206 
Lichen  planus,  687 

ruber  acuminatus,  688 

scrofulosus,  688 

simplex,  662 

tropicus,  749 

urticatus,  658 
Lieben's  iodoform  test,  218 
Lienteric  stools,  249 
Lightning  pains,  529 
Lipemia,  360 

Lipomatous  muscular  atrophy,  586 
Lithuria,  314 
Liver,  abscess  of,  286 

acute  yellow  atrophy  of ,  287 

albuminoid,  292 


INDEX 


7  73 


Liver,  amyloid,  292 

atrophic  cirrhosis  of,  289,  295 
atrophy  of,  287 
carcinoma  of,  294 
cirrhosis  of,  289 
congestion  of,  284 
corset,  283 
diseases  of,  282 
echinococcus  of,  293 
gin-drinker's,  289 
hob-nailed,  289 
hydatid  cyst  of,  293 
hypertrophic  cirrhosis  of,  289 
laced-off,  283 
lardaceous,  292 
location  of,  283 
sarcoma  of,  296 
spots,  714.  724 
syphilis  of,  294 
torpid,  284 
waxy,  292 
Lobar  pneumonia,  134 
Lobular  pneumonia,  512 
Localization,  cerebral,  S41,  561 
of  cerebral  hemorrhage,  549 
spinal,  580 
Lockjaw,  121 

Locomotor  ataxia,  589,  597,  603 
Lousiness,  720 
Lucid  interval,  627 
Ludwig's  angina,  204 
Lues,  89 

Lumbago,  167,  168 
Lumboabdominal  neuralgia,  607 
Lumbodynia,  168 
Lung,  abscess  of,  136 
gangrene  of,  136 
Lung-fever,  134 

Lungs,  cirrhosis  of  the,  156,  516 
•    congestion  of,  509 
diseases  of,  504 
edema  of,  511 
Lupoid  sycosis,  696 
Lupus  erythematodes,  741 
erythematosus,  741 
exedens,  743 
exulcerans,  743 
non-exedens,  741 
sebaceus,  741 
vorax,  743 
vulgaris,  743 
Lymphadenoma,  370 
Lymphatic  anemia,  370 

leukocythemia,  368,  369 
Lymphatism,  375 


Lymphocytes,  large,  357 

small,  357 

transitional  forms  of,  357 
Lysis,  definition  of,  4,  5 
Lyssa,  123 
Lyssophobia,  124 

McBurney's  point,  265 

MacEwen's  sign,  32 

Macrocythemia,  360 

Macules,  652 

Madness,  632 

Magnesium  test  for  phosphates,  316 

Malaria,  40,  54 

intermittent,  44 

pernicious,  48 

remittent,  47 

typho-,  21,  47 
Malarial  cachexia,  50 

fevers,  40,  54 

hematuria,  50 

hemoglobinuria,  50 

pneumonia,  139 
Malignant  anthrax  edema,  125 

cholera,  105 

endocarditis,  401 

fever,  bilious,  51 

intermittent  fever,  48 

jaundice,  287 

measles,  63 

pustule,  125 

quinsy,  77 

remittent  fever,  48 

scarlet  fever,  58 

small-pox,  68 
Malta  fever,  39 
Mania,  632 

delusional,  641 

reasoning,  643 
Mania-a-potu,  185,  186,  189 
Marsh  fever,  40,  47 
Mast  cells,  358 
Measles,  62 

Medicine,  practice  of,  defined,  i 
Mediterranean  fever,  39,  51 
Megaloblasts,  358 
Megalomania,  647 
Megrim,  567 
Melancholia,  629 

agitata,  629 

attonita,  629 

delusional,  641 

simplex,  629 
Melanemia,  360 
Melanoderma,  724 


774 


INDEX 


Melasma,  724 
Melena,  250 
Melituria,  176 
Membranous  angina,  77 

bronchitis,  495 

croup,  77 

enteritis,  255 
Meningeal  hemorrhage,.  549 
Meningismus,  533 
Meningitis,  533,  561 

acute,  535 

basilar,  538 

epidemic  cerebrospinal,  30 

spinal,  576 

tuberculous,  538 
Meniere's  disease,  564 
Mensuration,  448 
Mental  diseases,  627 
Mercurial  ptyalism,  203 

stomatitis,  203 
Metallic  tinkling,  462 
Microblasts,  358 
Micrococcus,  Bruce's,  39 

melitensis,  39 
Microcythemia,  360 

Microscopical  examination  of  the  blood, 
358 

of  the  sputum,  466 

of  the  stomach-contents,  219 

of  the  urine,  323 
Microsporon  furfur,  714 
Migraine,  567 
]\'^iliaria,  749 

alba,  749 

crystallina,  749 

papulosa,  750 

rubra,  749 

vesiculosa,  750 
Miliary  tuberculosis,  acute,  146 
Milium,  734 
Milk  sickness,  165 
Mind  center,  543 
Miosis,  531 
Mistura  enterica,  116 
Mitral  insufficiency,  403 

obstruction,  407,  410 

regurgitation,  403,  406,  407 

stenosis,  407,  410 
Mixed  treatment,  98 
Moebius'  sign,  378 
Moist  friction  sounds,  462 

r^les,  460 
Molluscum  contagiosum,  732 

epitheliale,  732 

sebaceum,  732 


Monanesthesia,  528 

Monomania,  643 

Monoplegia,  524 

Moore's  test  for  sugar,  318 

Morbid  anatomy,  definition  of,  2 

Morbilli,  62 

Morbus  maculosus  Werlhofii,  374 

Morphea,  738 

Morphinism,  192 

Morphinomania,  192 

Mosquitoes,  40,  41,  44,  46 

Moth,  724 

Motor  aphasia,  563 

area,  542 

phenomena,  523 

power  of  the  stomach,  219 
Mouth,  diseases  of,  198 
Movable  kidney,  349 
Mucous  catarrh,  490 

patches,  90 

stools,  249 
Mucus  in  urine,  317 
Muguet,  201 

Mueller's  blood-dust,  358 
Multiple  neuritis,  601 
endemic,  604 

sclerosis  of  the  brain  and  cord,  594 
Mumps,  75 
Murmurs,  387 
Muscles,  atrophy  of,  529 

degeneration  of,  529 

paralysis  of  laryngeal,  612 

trichina  in,  279 
Muscular  atrophy,  chronic  spinal,  584 
lipomatous,  586 
progressive,  584,  597 

paralysis,  pseudohypertrophic,  586 

rheumatism,  167 

sense,  529 

center  for,  542 
Mutism,  640 
Myalgia,  167 
Mycosis  intestinalis,  125 
Mycotic  endocarditis,  401 

stomatitis,  201 
Mydriasis,  531 
Myelitis,  acute,  578 

central,  578 

cortical,  578 

diffuse,  578  ' 

general,  578 

transverse,  5/8 
Myelocytes,  358 

Myelogenic  leukocythemia,  368,  369 
Myocarditis,  acute,  422 


INDEX 


775 


Myocarditis,  chronic,  423,  426 
interstitial,  423 
fibrous,  423 
Myocardium,  diseases  of  the,  417 
Myxedema,  379 

Nsevus  pilosus,  735 
Nails,  atrophy  of,  738 

hypertrophy  of,  736 
Narcotic  addiction,  Lambert's  treatment 

for,  193 

Nasal  catarrh,  acute,  468 

chronic,  471 

diphtheria,  8$ 

passages,  diseases  of,  468 
Neapolitan  fever,  39 
Nematodes,  276 
Nephritis,  acute,  336 

acute  croupous,  327 
desquamative,  327 
parenchymatous,  327 
tubal,  327 

catarrhal,  326 

chronic,  336 
croupous,  330 
interstitial,  333.  336 

parenchymatous,  330,  336 

suppurative,  339 

tubal,  330 
Nephrolithiasis,  341 
Nephroptosis,  349 
Nerves,  diseases  of,  599 
Nervous  diseases,  general,  613 

dyspepsia,  241 

exhaustion,  623 

fever,  14 

prostration,  623 

system,  diseases  of,  523.  532 

vertigo,  565 
Nettle-rash,  657 
Neuralgia,  529,  606 

cervico-brachial,  607 

cervico-occipital,  607 

dorso-intercostal,  607 

lumbo-abdominal,  607 

of  the  fifth  nerve,  606 

of  the  heart,  433 

of  the  stomach,  238 

red,  608 

trifacial,  606 
Neurasthenia,  622,  623 
Neurasthenic  stigmata,  623 
Neuritis,  degenerative,  601 

disseminated,  601,  604 

endemic  mvdtiple,  604 


Neuritis,  multiple,  6   i 

optic,  531 

peripheral,  601 

simple,  599 
Neuroglia,  540 
Neuron,  540 
Neuroses,  occupation,  625 

professional,  625 
Neutrophiles,  polymorphonuclear,  357 
New  growths  of  the  skin,  740 
Nocturnal  tetany,  381 
Noma,  202 

Non-obstructive  jaundice,  297 
Normoblasts,  358 

Nucleated  red  blood-cells,  358,  360 
Nutritive  disturbances,  529 
Nystagmus,  531 

Obermeier's  spirochete,  39 
Obstruction,  aortic,  411 

esophageal,  212 

intestinal,  269,  272 

mitral,  407,  410 

of  the  common  duct,  300 

of  the  cystic  duct,  300 

ptdmonary,  413 

tricuspid,  412 
Occlusion  of  the  cerebral  vessels,  553 
Occult  blood,  237 

hemorrhage,  237 
Occupation  neuroses,  625 
Ocular  vertigo,  564 
Oidium  albicans,  202 
Oinomania,  185,  187 
Oligemia,  361 
Oligochromemia,  359 
Oligocythemia,  359 
Oliguria,  312 
Onomatomania,  64O 
Onychauxis,  736 
Opisthotonos,  121 
Opium  poisoning,  chronic,  192 
Optic  atrophy,  531 

neuritis,  531 
Organic  dementia,  650 

endocardinal  murmurs,  387 

obstruction  of  the  esophagus,  212 
Oriental  plague,  119 
Orthopnea,  464 
Orthotonos,  121 
Oscillating  respiration,  428 
Osier's  disease,  371 
Oxalate,  calcium,  315,  316 
Oxalates,  315,  316 
Oxaluria,  316 


776 


INDEX 


Oxyuris  vermicularis,  277,  278,  280,  281 
Ozena,  471.  472 

Pacchionian  granulations,  533 
Pachymeningitis,  533 

externa,  533 

hypertrophic,  575 

interna,  533 

pseudomembranous,  575 

spinal,  575 

syphilitica,  534 
Pain  in  precordial  region,  319 
Palpation,  384,  447 
Palpitation  of  the  heart,  391,  428 
Palsy,  Bell's,  610 

infantile,  34 

shaking,  626 

wasting,  584 
Pancreas,  cancer  of,  304  - 

cysts  of,  304 

diseases  of,  302 
Pancreatic  calculi,  305 
Pancreatitis,  acute,  302 

chronic,  303 
Pandemic  diseases,  2 
Papillitis,  531 
Papules,  653 

Paradoxical  contraction,  527 
Paragraphia,  562 
Parallelism,  law  of,  130 
Paralysis,  523 

acute  ascending,  587 

agitans,  626 

alcoholic,  601 

amyothrophic,  597 

atrophic,  of  children,  34 

bulbar,  582 

chronic  progressive  bulbar,  582 

diver's,  198 

essential,  of  children,  34 

facial,  610 

general,  644 

glosso-labio-pharyngo-laryngeal,  582 

infantile,  34 

Landry's,  587 

of  laryngeal  muscles,  612 

of  the  insane,  general,  644 

pseudohypertrophic  muscular,  586 

spastic  spinal,  588 
Paralytic  insanity,  648 
Paranephritis,  34s 
Paranesthesia,  52S 
Paranoia,  643 
Paraphasia,  562 
Paraplegia,  524 


Paraplegia,  ataxic,  593,  597 
hereditary  ataxic,  596 
primary  spastic,  597 
Parasite  of  malaria,  42 
Parasites,  273 

intestinal,  273 
in  the  blood,  360 
Parasitic  diseases  of  the  skin,  707 

stomatitis,  201 
Parasyphilitic  diseases,  01 
Paratyphoid  fever,  28 
Parenchymatous  hepatitis,  286,  287 

nephritis,  327.  330,  336 
Paresis,  644 

general,  644 
Paresthesia,  529 
Paretic  dementia,  644 
Parietal  appendicitis,  265 
Parkinson's  disease,  626 
Parotitis,  75 

Paroxysmal  rapid  heart,  429 
Parrot's  nodes,  loi,  103 
Parry's  disease,  377 
Partial  cerebral  anemia,  553 

dementia,  650 
Pasteur  treatm^ent,  124 
Patellar  reflex,  526 
Pathogenesis,  definition  of,  i 
Pathology,  definition  of,  i 
Pectoriloquy,  463 
Pediculosis,  720 

capitis,  721 

corporis,  721 

pubis,  722 

vestimenti,  721 
Pediculus  capitis,  721 

pubis,  722 
Peliosis  rheumatica,  375 
Pellagra,  195 
Pemphigus,  683 

foliaceus,  684 

haemorrhagicus,  683 

malignus,  684 

pruriginosus,  684 

vegetans,  684 

vulgaris,  683 
Pepsin,  test  for,  218 
Peptic  ulcer,  227 
Peptone,  218,  322 
Percussion,  384,  449 

auscultatory,  453 

respiratory,  453 
Perforating  ulcer  of  the  {oot,  530 
Pericardial  dropsy,  398 

murmurs,  387 


INDEX 


777^ 


Pericarditis,  acute,  393 
adhesive,  397 
chronic,  397 
Pericardium,  adherent,  397 
diseases  of  the,  393 
empyema  of,  397 
Perinephritic  abscess,  34s 
Period  of  compensation,  403 

of  incubation,  definition  of,  3 
Peripheral  neuritis,  601 
Peritoneum,  diseases  of,  305 

inflammation  of,  305 
Peritonitis,  272,  305 

acute,  306 

chronic,  307 
Perityphlitis,  264 
Pernicious  anemia,  365 

malarial  fever,  48 
Pertussis,  126 
Petechiae,  374 
Petechial  fever,  30 

typhus,  28 
Petit  mal,  le,  615 

Pettenkofer's  test  for  bile-pigment,  321 
Pfeififer,  bacillus  of,  10 
Phantom  tumor,  621 
Pharyngitis,  acute  catarrhal,  207 

chronic,  208 

granular,  208 

phlegmonous,  209 
Pharynx,  diseases  of,  207 

ulceration  of,  209 
Phenomena,  motor,  523 

sensory,  527 
Phenyl-hydrazine  test,  319 
Phlegmonous  erysipelas,  74 

pharyngitis,  209 
Phosphate,  ammonio  magnesium,  314 
Phosphates,'*3i4,  315,  316 
Phosphaturia,  315 
Phosphoridrosis,   746 
Phthiriasis,  720 
Phthisical  chest,  446 
Phthisis,  acute,  146 

caseous,  149 

catarrhal,  149 

chronic,  ulcerative,  152 

fibroid,  156 

florida,  150 

incipient,  152 

laryngeal,  483 

pneumonic,  149 

tuberculous,  152 
Physical  diagnosis,  382,  442 

signs,  definition  of,  3 


Physical  signs,  association  of,  464 
Pia,  532 

Pia-arachnoid,  532 
Piano-player's  cramp,  625 
Piroplasmosis,  119 
von  Pirquet's  test,  155 
Pityriasis,  751 

maculata  et  circinata,  700 
rosea,  700 
versicolor,  714 
Plague,  119 

bubonic,  119 
Oriental,  119 
Plasmodium,  Laveran's,  40 
malariae,  40,  42,  43 
praecox,  42,  43 
vivax,  42,  43 
Plastic  bronchitis,  495 
endocarditis,  399 
Pleura,  diseases  of  the,  516 

dropsy  of,  521 
Pleural  cavity,  air  in  the,  522 

r^les,  461 
Pleurisy,  516 
Pleuritis,  516 
Pleurodynia,  167,  168 
Pleuro-pneumonia,  136 
Pleurosthotonos,  121 
Pneumococcus,  Friedlander's,  134 
Pneumonia,  alcoholic,  140 
apical,  140 
apyretic,  140 
aspiration,  140 
basal,  140 
bilious,  139 
caseous,  149 
catarrhal,  512 
central,  140 
chronic  catarrhal,  149 
interstitial,  156,  516 
creeping,  140 
croupous,  134 
double,  136,  140 
ether,  140 
fibrinous,  134 
fibroid,  516 
in  children,  140 
intermittent,  139 
in  the  aged,  140 
latent,  140 
lobar,  134 
lobular,  512 
malarial,  139 
massive,  140 
migratory,  140 


778 


INDEX 


Pneumonia  of  the  insane,  140  , 

of  the  intemperate,  140 

post-operative,  140 

terminal,  140 

traumatic,  140 

typhoid,  139 
Pneumonic  phthisis,  149 
Pneumonitis,  134 
Pneumothorax,  522 
Podagra,  172 
Poikilocytes,  367 
Poikilocytosis,  360 
Poisons  and  antidotes,  222 
Polymorphonuclear  neutrophils,  357 
Poliomyelitis,  acute,  34 

chronic,  584 

epidemic,  34 
Polyneuritis,  601 
Polynuclear  leukocytes,  357 
Polyuria,  183,  312 
Pomphi,  653 
Pompholyx,  685 
Pons  hemorrhage,  549 
Postepileptic  automatism,  616 

mania,  637 
Posterior  sclerosis,  combined  lateral   and, 

593 

spinal  sclerosis,  589 
Pox,  the,  89 

Practice  of  medicine,  definition  of,  i 
Precordium,  382 
Pre-epileptic  mania,  637 
Prickly  heat,  749 
Primary  anemia,  361 

delusional  insanity,  641 

dementia,  650 

lateral  sclerosis,  588 

spastic  paraplegia,  597 
Proctitis,  268 
Prodromes,  3 
Professional  neuroses,  625 
Proglottides,  275 
Progressive  bulbar  paralysis,  chronic,  582 

muscular  atrophy,  584 

pernicious  anemia,  365 
Prolonged  respiration,  457 
Propeptone,  test  for,  218 
Prosopalgia,  606 
Proteus  vulgaris,  264 
Prurigo,  688 
Pruritus,  754 

ani,  756 
Pseudoangina,  434 
Pseudodiphtheria,  77 
Pseudohydrophobia,  124 


Pseudohypertrophic    muscular     paralysis, 

586 
Pseudoleukemia,  370 

splenic,  376 
Pseudoleukocythemia,  370 
Pseudomembranous,  enteritis,  255 

pachymeningitis,  57s 
Pseudomuscular  hypertrophy,  586 
Pseudotabes,  601 
Psoriasis,  696 

circinata,  697 

diffusa,  698 

guttata,  697 

gyrata,  697 

nummularis,  697 

palmaris  et  plantaris,  698 

piinctata,  697 

unguium,  698 
Psychalgia,  629 
Ptyalism,  mercurial,  203 
Puking  fever,  165 
Pulmonary  edema,  511 

engorgement,  509 

insufficiency,  410 

obstruction,  413 

regurgitation,  410 

stenosis,  413 

tubercvilosis,  146 
treatment  of,  iS7 
Pulse,  389 

in  fever,  6 

irregularity  of  the,  431 

relation  of,  to  temperature,  6 
Pulsus  paradoxus,  390 
Pupil,  Argyll-Robertson,  531 
Pupils,  unequal,  531 
Purging,  249 
Purpura,  374 

haemorrhagica,  374 

scorbutic,  372 

simplex,  374 

urticans,  374 
Purulent  stools,  249 
Pus  in  urine,  321 
Pus-casts,  32s 
Pustule,  malignant,  125 
Pustules,  653 
Putrid  fever,  28 

sore  mouth,  201 
Pyelitis,  339 
Pyelonephritis,  339.  340 
Pyloric  obstruction,  234 

stenosis,  234   \ 
Pyonephrosis,  339.  340 
Pyrexia,  definition  of,  5 


INDEX 


779 


Pyrexia,  degrees  of,  5 
Pyrosis,  240 
Pyuria,  321- 

Quartan  fever,  42 

parasite,  42 
Quick  heart,  429 
Quincke's  disease,  660 
Quinsy,  209 

malignant,  77 
Quotidian  fever,  42 

Rabies,  123 

Rachitic  chest,  446 

Rachitis,  173 

Rales,  459 

Ralfe's  test  for  peptone,  322 

Rapid  heart,  429 

Rashes,  vaccination,  72 

Raynaud's  disease,  624 

Reaction,  Calmette's  155 

desmoid,  of  Sahli,  218 

diazo,  20,  322 

of  degeneration,  35 

Sahli's  desmoid,  218 

Schick's,  83 

Widal's,  20 
Reasoning  mania,  643 
Rectitis,  268 
Rectum,  catarrh  of,  268 
Red  blood-cells,  358 

hepatization,  135 

neuralgia,  608 

stools,  250 
Reflexes,  526 
Regurgitation,  aortic,  404 

mitral,  403 

pulmonary,  410 

tricuspid,  409 
Relapsing  fever,  38 
Relation  of  pulse  to  temperature,  6 
Remittent  fever,  6,  47 
bilious,  47 
malignant,  48 
Renal  calculi,  341 

colic,  341 

hyperemia,  326 
Rennet,  test  for,  218 
Respiration,  Cheyne-Stokes,  428,  530 

oscillating,  428 
Respiratory  percussion,  453 

system,  diseases  of,  442 
Retrocedent  gout,  173 
Rheumatic  fever,  129 
Rheumatism,  acute  articular,  129 


Rheumatism,  chronic  articular,  166 

inflammatory,  129 

muscular,  167 
Rheumatoid  arthritis,  169 
Rhinitis,  acute,  468 

atrophic,  471 

chronic,  471 

hypertrophic,  471 
Rhinophyma,  694 
Rhus  poisoning,  701 
Rhythm,  respiratory,  457 
Rickets,  175 
Ringworm  of  the  beard,  712 

of  the  body,  707 

of  the  nails,  708 

of  the  scalp,  709 
Risus  sardonicus,  121 
Roberts'  test  for  sugar,  320 
Rock  fever,  39 

Rocky  Mountain  spotted  fever,  165 
Roetheln,  65 

Romberg's  symptom,  590 
Rosacea,  693 
Rose,  the,  73 

cold,  497 
Roseola,  epidemic,  65 
Round  ulcer,  227 

worms,  276 
Rovsing's  sign,  266 
Rubella,  65 
Rubeola,  62 

Ruptured  compensation,  403 
Rush  of  blood  to  the  head,  544 
Russo's  test,  323 

Sahli's  desmoid  reaction,  218 

Sailor's  fever,  51 

Salt  rheum,  661 

Salvarsan,  96 

Sarcoma  of  the  liver,  296 

Sarcoptes  scabiei,  717 

Scabies,  717 

Scall,  661 

Scalp,  ringworm  of  the,  709 

Scarlatina,  56 

miliaris,  57 
Scarlet  fever,  56 
Schoenlein's  disease,  375 
Schick's  reaction,  83 
Sciatica,  607 
Sclerema,  737 
Scleroderma,  737 

circumscribed,  738 
Slcerosis,  amyotrophic  lateral,  s88 

anterolateral,  588 


78o 


INDEX 


Sclerosis,  cerebral,  594 
cerebrospinal,  594 

combined  lateral  and  posterior,  593 

disseminated,  594 

insular,  594 

lateral,  597 

of  the  brain  and  cord,  multiple,  594 

of  the  kidneys,  333 

posterior,  593 
spinal,  589 

primary  lateral,  588 

spinal,  587,  594 
Scolices,  273   ' 
Scorbutic  purpura,  372 
Scorbutus,  372 
Scrofuloderma,  74s 
Scurvy,  372 

infantile,  373 
Sebaceous  cyst,  735 

tumor,  735 
Seborrhea,  751 

capitis,  752 

congestiva,  751 

oleosa,  752 

sicca,  752 
Secondary  anemia,  361 

bronchitis,  489 

cerebral  abscess,  557 

dementia,  651 
Secretion,  disorders  of  (of  skin),  745 
Senile,  emphysema,  504 

melancholia,  629 

vertigo,  565 
Sensation,  disorders  of  (of  skin),  754 
Sense,  muscular,  529 

of  position,  529 
Sensory  aphasia,  563 

area,  542 

phenomena,  527 
Septic  endocarditis,  401 
Sequential  dementia,  651 
Serous  apoplexy,  570 

stools,  249 
Seven-day  fever,  38 
Shaking  palsy,  626 
Shiga's  bacillus,  112,  258 
Shingles,  604 
Ship  fever,  28 
Shortness  of  breath,  464 
Sick  headache,  567 
Sign,  Brudzinski's,  32 

Corrigan's,  439 

Graefe's,  378 

Kernig's,  31,  32 

MacEwen's,  32 


Sign,  Moebius',  378 

Rovsing's,  266 

Stellwag's,  378 
Skin,  anemia  of,  653 

anesthesia  of,  527 

atrophies  of,  737 

diseases  of,  652 

disorders  of  secretion  of,  745 

glossy,  529 

hyperemia  of,  653 

hypertrophies  of,  723 

inflammations  of,  654 

lesions  of,  652 

new  growths  of,  740 

trophic  disturbances  of,  530 
Sleeping  sickness,  118 
Small-pox,  66 
Small  pulse,  391 

red  kidney,  333.  336 

white  kidney,  336 
Smoker's  patches,  206 

tongue,  206 
Soft  pulse,  391 
Softening,  cerebral,  553 

of  the  cord,  578 
Somnambulism,  531 
Soor,  201 

Sore  mouth,  putrid,  201 
Sore  throat,  207,  474 

clergyman's,  208 
Sounds,  cardiac,  385 

respiratory,  in  disease,  456 
in  health,  454 
Spasm  of  glottis,  480 
Spasmodic  asthma,  500 

croup,  479 

laryngitis,  479,  480 

tabes  dorsalis,  588 
Spastic  gait,  525 

paraplegia  primary,  597 

spinal  paralysis,  588 
Spermatozoa  in  urine,  325 
Special  senses,  disturbances  of,  531 
Speech  center,  542,  562 
Spinal  congestion,  573 

hyperemia,  573 

leptomeningitis,  576 

muscular  atrophy,  chronic,  584 

paralysis,  spastic,  588 
Spinal  cord,  diseases  of,  573 

hyperemia,  573 

localization,  580 

meningitis,  576 

pachymeningitis,  575 

sclerosis,  587,  594 


INDEX 


781 


Spinal  cord,  softening  of  the,  578 
Spirals,  Curschmann's,  467 
Spirillum  fever,  38 
Spirochaeta  cholerse,  105 
darticola,  86 
nodosa,  166 
Obermeieri,  38,  39 
pallida,  89 
Splenic  anemia,  376 
fever,  125 

leukocythemia,  368,  369 
pseudoleukemia,  376 
Spleno-myelogenous  leukemia,  369 
Sporadic  cholera,  256 

diseases,  2 
Spotted  fever,  28,  30 

Rocky  Mountain,  165 
Sputum,  46s,  466 
Squibb's  cholera  mixture,  no 

diarrhea  mixture,  251 
St.  Anthony's  fire,  73 
St.  Vitus'  dance,  613 
Starch-products,  test  for,  218 
Starvation  treatment  of  diabetes,  180 
Status  epilepticus,  616 
lymphaticus,  375 
Steatoma,  735 
Stegomyia,  41,  44,  51 

fasciata,  44,  Si 
Stellwag's  sign,  378 
Stenocardia,  433 
Stenosis,  aortic,  411 
mitral,  410 
pulmonary,  413 
tricuspid,  412 
Steppage  gait,  526 
Stigmata,  neurasthenic,  623 
Stitch  in  the  side,  516 
Stokes- Adams  syndrome,  432 
Stomach,  cancer  of,  231 

diagnostic  technic,  214 
dilatation  of,  234 
diseases  of,  214 
external  examination  of,  214 
hemorrhage  from,  236 
internal  examination  of,  215 
neuralgia  of,  238 
tube,  contraindications  of,  215 
ulcer  of,  227 
Stomach-contents,    examination    of,    215, 

219 
Stomachic  colic,  238 
Stomatitis,  aphthous,  200 
catarrhal,  199 
chronic,  199 


Stomatitis,  croupous,  200 

epidemic,  88 

erythematous,  199 

fetid,  201 

follicular,  200 

herpetic,  200 

gangrenous,  202 

mercurial,  203 

mycotic,  201 

parasitic,  201 

pseudomembranous,  201 

simple,  199 

ulcerative,  201 

vesciular,  2oq 
Stomatomycosis,  201 
Stomoxys  calcitrans,  19S 
Stone  in  the  kidney,  341 
Stools,  250 

Strangulation,  intestinal,  269,  272 
Strawberry  tongue,  58,  204 
Streptococcus  erysipelatis,  73 
Strobila,  275 
"Stroke,"  547 
Strong  pulse,  391 
Strophulus  albidus,  734 
Subacidity,  216 

Subacute  disease,  definition  of,  3 
Subsultus  tendinum,  16 
Succussion,  463 
Sudamen,  749 
Sudamina,  749 
Sugar  in  the  urine,  318 
Summer  complaint,  262 
Sun  cholera  mixture,  no 
Sunstroke,  195 
Superfluous  hair,  735 
Suppressed  respiration,  457 
Suppurative  encephalitis,  557 

hepatitis,  286 

nephritis,  339 

pancreatitis,  303 
Surgical  kidney,  339 
Swamp  fever,  40 
Sycosis,  lupoid,  696 
parasitica,  712 
vulgaris,  695 
Sydenham's  chorea,  613 
Syphilis,  89 

acquired,  90 

congenital,  loi 

hereditary,  72,  89,  loi 

late,  103 

of  the  liver,  294 

of  the  tongue,  205 

secondary,  72 


782 


INDEX 


Syphilis,  skin  eruptions  of,  92,  95.  100 

Syphilitic  laryngitis,  483,  484 

skin  rashes,  92,  95.  100 

ulcer  of  pharynx,  209 

wig,  102 
Syringomyelia,  597 
Syringomyelitis,  597 

Tabardillo,  28 
Tabes  dorsalis,  589 

spasmodic,  588 
Tabetic  arthropathies,  591 
Tache  cerebrale,  536 
Tachycardia,  390,  429 
Taenia  echinococcus,  273,  274.  275.  293 

mediocanellata,  274,  275 

saginata,  273,  274,  275 

solium,  273.  274.  275 
Tapeworms,  273,  274 
Teeth,  Hutchinson's,  102 
Telegraphist's  cramp,  625 
Temperature,  5 

subnormal,  5 

relation  of,  to  pulse,  6 
Temvdentia,  185 
Tendon  reflexes,  526 
Tension  of  the  pulse.  391 
Terminology,  4 
Tertian  fever,  42 

parasite,  42 
Test,  or  tests: 

Boas',  216 

Boettger's,  318 

Davy's,  313 

Ehrlich's  diazo,  322 

Esbach's,  318 

Fehling's,  319 

for  acetic  acid,  218 

for  acetone,  321 

for  albumin,  317 

for  alcohol,  218 

for  bile,  321 

for  blood  in  the  urine,  320 

for  butyric  acid,  217 

for  chlorides,  316 

for  determination  of  motor  power  of 
the  stomach,  219 

for  diacetic  acid,  322 

for  free  acids,  216 

for  free  hydrochloric  acid,  216,  217 

for  indican,  322 

for  lab  ferment,  218 

for  lactic  acid,  217 

for  mucus,  317.  321 

for  pepsin,  218 


Test  for  peptone,  218,  322 

for  phosphates,  316 

for  propeptone,  218 

for  pus,  321 

for    rate    of    absorption    of    stomach 
contents,  219 

for  rennet,  218 

for  starch  products,  218 

for  sugar,  318 

for     total     acidity     of     the     gastric 
contents,  217 

for  urates,  314 

for  urea,  313 

for  uric  acid,  314 

Fowler's,  313 

Gmelin's,  321 

Guenzburg's,  216 

heat  and  nitric  acid,  318 

Heller's,  317.  321 

iodoform,  218 

JafEe's,  322 

Johnson,  318,  319 

Legal's,  322 

Lieben's,  218 

Moore's,  318 

Pettenkofer's,  321 

phenylhydrazin,  319 

von  Pirquet's,  155 

Ralfe's,  322 

Roberts,'  320 

Russo's,  323 

SahH's,  218 

Toepfer's,  217 

Trommer's,  319 

tuberculin,  155 

Uffelmann's,  217 

Widal's,  20 
Test  meal.  Boas',  215 

Ewald's,  215 

Leube-Riegel,  215 
Tetanic  convulsions,  524 
Tetanilla,  380 
Tetanus,  121 

cephalic,  121 

idiopathic,  121 

intermittent,  380 

neonatorum,  121 

traumatic,  121 
Tetany,  380,  480 

nocturnal,  381 
Tetter,  661 
Thermic  fever,  195 
Thermoanesthesia,  528 
Thoma-Zeiss  hemocytometer,  356 
Thoracic  aorta,  anevirysm  of  the,  441 


INDEX 


783 


Throat  consumption,  483 
Thrombosis,  cerebral,  553 
Thrush,  201 
Thymic  asthma,  480 
Thyroidism,  380 
Tic  doulourex,  606 
Tinea  circinata,  707,  7 10 
cruris,  707,  708 

favosa,  715 

epidermidis,  715 
pilaris,  715 
pilaris  et  capitis,  716 
unguium,  715,  716 

furfuracea,  751 

kerion,  710 

sycosis,  712 

tonsurans,  709 

tricophytina  barbae,  712 
capitis,  709 
corporis,  707 
unguium,  708 

versicolor,  714 
Tinnitus  aurium,  532 
Titubation,  526 
Toepfer's  test,  217 
Tongue,  coating  of,  204 

diseases  of,  204 

epithelioma  of,  206 

geographical,  204 

ichthyosis  of,  206 

inflammation  of,  205 

smoker's,  206 

strawberry,  58,  204 

syphilis  of,  205 

ulceration  of,  205 
Tonsillar  abscess,  209 
Tonsillitis,  acute,  209 
Tonsils,  diseases  of,  207 

hypertrophy  of,  211 
Tormina,  246 
Torpid  liver,  284 
Torpor,  intestinal,  247 
Torticollis,  167,  168 
Total  acidity  of  gastric  contents,  217 
Toxic  erythema,  654 

gastritis,  220,   222 
Tracheal  ra,les,  460 

tugging,  439 
Trance,  530,  622 
Transitional  lymphocytes,  357 
Transverse  myelitis,  578 
Trapp's  coefficient,  312 
Traube's  semilunar  space,  214,  451 
Traumatic  pneumonia,  140 

tetanus,  I2i 


Trembles,  165 
Tremors,  525 

intentional,  595 
Treponema  pallidum,  89 
Triad,  Hutchinson's,  102 
Trichina  spiralis,  277,  278,  280 
Trichiniasis,  280,  281 

Trichocephalus  dispar,  277,  279,  281,  282 
Tricophyton,  707,  709,  712 
Tricuspid  insufficiency,  406,  409 

obstruction,  412 

regurgitation,  406,  409 

stenosis,  412 
Triple  phosphate,  314 
Trismus,  121 

Trommer's  test  for  sugar,  319 
Trophic  disturbances  of  the  skin,  530 
Tropical  dysentery,  112 

splenomegaly,  119 
Trousseau's  sign,  381 
Trypanosoma  gambiense,  118 

ho  minis,  118 
Trypanosomiasis,  118 
Tubal  nephritis,  acute,  327 

chronic,  330 
Tube  casts,  324 
Tubercle  bacillus,  467,  743 

bacilli  in  urine,  325 
Tubercles,  152,  653 
Tuberculin  test,  155 
Tuberculosis,  146,  152 

acute  miliary,  146 

of  the  kidney,  34s 

pulmonary,  146 
Tuberculous  laryngitis,  483 

meningitis,  538 

phthisis,  152 

ulcer  of  intestine,  15 
of  pharynx,  209 
Tumor,  cerebral,  559,  561 

intracranial,  559 

phantom,  621 

sebaceous,  735 
Tumors,  653 
Tunnel  anemia,  280 
Tussive  fremitus,  448 
Twists,  intestinal,  269,  272 
Tyloma,  726 
Tympanitic  note,  452 
Typhilitis,  264 
Typhoid  carriers,  22 

cholera,  105 

fever,  14 

state,  19 

variety  of  tuberculosis,  147 


784 


INDEX 


Typho-malarial  fever,  21,  47 
Typho mania,  633 
Typhoid  pneumonia,  139 

ulcer  of  intestine,  15 
Typhus,  abdominal,  14 

exanthematic,  28 

fever,  28 

icterodes,  51 

petechial,  28 
Tyrosin,  317 

Uffelmann's  test,  217 
Ulcer,  duodenal,  227 

gastric,  227 

of  the  pharynx,  209 

of  the  stomach,  227 

of  the  tongue,  205 

peptic,  227 

perforating,  of  foot,  530 

round, 227 

simple,  227 

tuberculous,  of  the  intestine,  15 

typhoid,  of  the  intestine,  15 
Ulcerative  appendicitis,  264 

endocarditis,  401 

enterocolitis,  258 

phthisis,  chronic,  152 

stomatitis,  201 
Ulcers,  vaccination,  72 
Uncinaria,  278 
Uncinariasis,  280,  282 
Undulant  fever,  39 
Unequal  pupils,  531 
Urate,  ammonium,  315 
Urates,  314 
Urea,  313 
Uremia,  acute,  345 
Uremic  coma,  34s 

convulsions,  34s 

intoxication,  345 

poisoning,  34s 
Uric  acid,  314 

acid  crystals,  314 

acid,  tests  for,  314 
Uridrosis,  746 
Urinalysis,  312 

Urinary  organs,  diseases  of,  311 
Urine,  311 

composition  of,  313 
examination  of,  312 
chemical,  313 
microscopical,  323 
Urticaria,  657 

ab  ingestis,  658 
annularis,  658 


Urticar;^.  bullosa,  658 
CO'      -ta.  658 
evanida,  658 
factitia,  658 
febrilis,  658 
figurata,  658 
haemorrhagica,  658 
papulosa,  658 
perstans,  658 
pigmentosa,  658,  660 
purpurata,  658 
tuberosa,  658 
vesiculosa,  658 

Vaccinia,  70 
Vaccination,  70 

rashes,  .72 

ulcers,  72 
Vaccino-chancre,  72 

-syphilis,  72 
Valvular  defects,  combined,  413 
relative -frequency  cf,  413 

diseases,  chronic,  402 
diagnosis  of,  414 

prognosis  of,  415 

treatment  of,  415 
Valvulitis,  399 
Vaquez's  disease,  371 
Varicella,  73 
Variola,  66 
Varioloid,  66,  68 
Vasomotor  disturbances,  527 
Ventricular  hemorrhage,  549 
Verbal  amnesia,  563 
Vemix  caseosa,  751 
Verruca,  730 

acuminata,  731 

digitata,  731 

filiformis,  731 

plana,  731 

vulgaris,  731 
Verrucae  vegetantes,  731 
Vertigo,  564 

auditory,  564 
Vesicles,  653 
Vesicular  emphysema,  504 

riles,  460 

stomatitis,  200 
Vesiculobronchial  respiration,  45 S 
Vincent's  angina,  86 
Violin-player's  cramp,  625 
Visual  center,  542 
Vitiligo,  737 
Vitiligoidea,  740 
Vleminckx's  solution,  69S 


INDEX 


78s 


Vocal  fremitus,  448  * 

resonance,  462 
Voice  in  health,  455 

in  disease,  462 
Volvulus,  269,  272 
Vomit,  black,  51 

Wandering  kidney,  349 
Wart,  730 

Wassermann  reaction,  96 
Wasting  palsy,  584 
Water-cancer,  202 
Water-hammer  pulse,  391,  405 
Water-on-the-brain,  570 
Watery  stools,  249 
Waxy  casts,  325 

kidney,  338 

liver,  292 
Weak  pulse,  391 

Weichselbaum's  diplococcus,  30,  31 
Weil's  disease,  166 
Wen,  735 

Westphal's  phenomenon,  527 
Wheals,  653 
White  blood-cells,  357 

kidney,  small,  336 


White  pneumonia,  101 
Whooping  cough,  126 
Widal  reaction,  20 
Winter  cough,  489 
Wool-sorter's  disease,  125 
Word  blindness,  563 

deafness,  563 
Worms,  273,  732 

round,  276 

tape,  273 
Writer's  cramp,  625 

Xanthelasma,  740 
Xanthoma,  740 

planum,  740 

tuberosum,  740 
Xeroderma,  725 

Yellow  atrophy,  acute,  287 
fever,  51.  54 
hepatization,  136 
Jack,  51 

Zona,  604 

Zoster,  herpes,  604 


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